Barriers to Cataract Surgery in Africa: A Systematic Review

Exploring the burden of non-communicable diseases on surgical services in Africa: a comprehensive literature review

Introduction

Non-communicable diseases (NCDs) encompass five major categories: cardiovascular disease, cancer, diabetes mellitus, mental health disorders, and chronic respiratory diseases. The burden of NCDs is rising in Africa, particularly in sub-Saharan Africa, having increased by 67% from 1990 to 2017, which puts additional pressure on healthcare services. Although most treatments for NCDs are non-surgical, surgical intervention plays a crucial role in managing many of these diseases. Unfortunately, barriers to accessing surgical care for NCDs remain in Africa.

Methods

A comprehensive literature review was conducted employing the following search databases: AJOL, PubMed/Medline, and Google Scholar. Search strategies that combined terms pertaining to "non-communicable disease," "surgical care," and "Africa" were utilized.

Results

The main barriers to surgical access in the management of NCDs in Africa include restricted financial resources, a lack of adequate infrastructure, and deficiencies in competent surgical training. Measures to improve surgical intervention associated with NCDs include international collaborations, improved education and training of professionals, and the use of mobile technology tools.

Discussion

There is a need to implement strategies that seek to improve access to surgery for the treatment of NCDs on the African continent. Some of these strategies involve multi-professional action alongside the establishment of prevention actions and policies aimed at the management of NCDs. Furthermore, support from the governments of each nation, as well as ongoing research on the subject, also contribute to better development of surgical care for these diseases in the African context.

Predictors of time to recovery from cataract surgery among cataract patients at Menelik II Comprehensive Specialized Hospital: a retrospective follow up study

BACKGROUND

Cataracts are the leading cause of reversible blindness globally, disproportionately affecting populations in low- and middle-income countries. In Ethiopia, cataracts remain a significant public health concern. Despite the effectiveness of cataract surgery in restoring vision, information on recovery time and its predictors remain limited. The aim of this study was to assess time to recovery and its predictors among patients undergoing cataract.

METHODS

A retrospective cohort study was conducted on 459 cataract patients who underwent surgery between January 1 and December 31, 2023. Data were randomly extracted from their medical records between June 1 and August 15, 2024. The Kaplan-Meier method was used to estimate the survival probabilities and compare groups, with significant differences tested using the log-rank test. The Weibull regression with the inverse Gaussian frailty was applied following a goodness-of-fit test to identify predictors of time to recovery. Results are presented as adjusted hazard ratios (AHRs) with 95% confidence intervals (CIs). All statistical tests were declared significant at P-value < 0.05.

RESULTS

we reviewed 459 patient cards, and 368 (80.17%, 95% CI: 76.26-83.58%) had recovered from a cataract surgery over 7,919.28 person-weeks. The overall incidence rate of recovery was at 46.47 per 1,000 persons per week (95% CI: 41.95-51.47). The median recovery time was at 18.14 weeks (IQR: 12.29-24, 95% CI: 17.14-18.86). Age over 60 years (AHR = 0.25, 95% CI: 0.07-0.96), urban residence (AHR = 1.77, 95% CI: 1.15-2.70), preoperative visual acuity (medium: AHR = 1.98, 95% CI: 1.23-3.18; high: AHR = 5.83, 95% CI: 1.72-19.77), comorbidities (ocular: AHR = 0.30, 95% CI: 0.15-0.61; systemic: AHR = 0.41, 95% CI: 0.22-0.75), type of surgery (phacoemulsification: AHR = 1.98, 95% CI: 1.06-3.67; intracapsular cataract extraction: AHR = 0.14, 95% CI: 0.03-0.89), and complications (intraoperative: AHR = 0.29, 95% CI: 0.12-0.71; postoperative: AHR = 0.17, 95% CI: 0.06-0.47), and surgeries performed by an ophthalmologist (AHR = 3.44, 95% CI: 1.80-6.55) were statistically significant predictors of time to recovery from cataract surgery.

CONCLUSION

The median recovery time was shorter than in previous local studies but longer than in developed countries. Improved preoperative assessment, better comorbidity management, and minimizing complications may contribute to better recovery outcomes. The use of phacoemulsification and procedures performed by experienced ophthalmologists were associated with shorter recovery times, but further prospective studies are needed to confirm these findings. Personalized care approaches are recommended to optimize postoperative recovery.

Ophthalmologists' Perspective on Barriers to Cataract Surgery and Surgical Productivity in Ethiopia, Ghana, and Zambia: A Descriptive, Mixed-Methods Survey

PURPOSE

While progress was made towards the Vision 2020: The Right to Sight goals, Ethiopia, Ghana, and Zambia fell short of the recommended cataract surgical rate (CSR) on a national level. Post-operative cataract surgical outcomes are also lower compared to other regions. This study aimed to describe perceived barriers to cataract surgical uptake, factors related to surgeon surgical productivity, and surgical offerings in each of these countries.

METHODS

An online survey was sent to ophthalmologists practicing in Ethiopia, Ghana, and Zambia. Responses were collected between June 25, 2021 and January 30, 2022.

RESULTS

Responses were received from 122 ophthalmologists from Ethiopia, Ghana, and Zambia. The estimated participation rate was 47% (122/257). Distance to cataract surgical centres, lack of surgical centres, and lack of surgical equipment were among the top 10 most agreed upon barriers by respondents within each country. Many respondents reported that current financial reimbursement does not incentivise maximum productivity in themselves (56%, 68/122) or their staff (61%, 74/122). Surgeons proposed several ways to improve productivity incentives. Private practice was perceived to have the best reimbursement incentives (77%, 94/122), whereas government hospitals were least agreed upon (4%, 5/122). Discrepancies in timely post-operative refraction and eyeglasses disbursement were reported.

CONCLUSIONS

Overcoming the identified barriers, improving surgeon productivity, and addressing identified deficits in cataract care will likely reduce the backlog of cataract blindness while ensuring increasingly improved patient outcomes.

Differences in need for and access to eye health services between older people with and without disability: A cross-sectional survey in four districts of northern Uganda

Eye health and disability are both common among older people, and it is important to understand how disability relates to visual health status and access to services. While people with disabilities face barriers to accessing health services, few studies have measured participants' functional status in domains other than vision and little evidence exists on how disability impacts eye health services access. This paper describes how visual impairment and access to eye health services differ between people aged 50 years and above with and without disability in Karamoja, Uganda, and explores the factors driving that difference. This was a cross-sectional survey among individuals aged 50 years and above. A standardised eye health survey was conducted, with additional questions on personal and health characteristics. Ophthalmologists conducted a vision examination, and recorded participants' self-reported functional difficulties using the Washington Group Short Set Enhanced. Descriptive analyses were conducted using Stata, and multivariate models constructed to explore relationships. 21.7% of respondents self-reported some sort of functional difficulty. Twenty-five percent of individuals with a non-visual functional difficulty are also blind, and a further 29% experience a lower level of VI. In a multivariate model, blindness was associated with self-reported difficulties seeing, but not any other type of difficulty. Blindness was also associated with age, not being married, and living in a smaller household. Access to cataract surgery was associated with non-visual functional difficulties, male gender, and having a regular household income. This study confirms that in the study area, disability and visual impairment are common among people aged 50 years and above, access to eye health services is low, and self-reported functional difficulties are not associated with lower access to services.

Assessing the cataract surgical rate and gender equity in cataract services in south-east Nigeria

BACKGROUND

In 2020, almost 100 million people were blind or visually impaired from cataract. Cataract surgery is a cost-effective treatment for cataracts. In Nigeria, twice as many women are cataract blind as men. Cataract surgical rate (CSR, the number of cataract operations per million population per year in a defined geographical location) is an output indicator of cataract surgical services. The recommended target CSR for sub-Saharan Africa is 1000/year. The aim of this study was to assess the CSR in men and women in Imo state, Nigeria.

METHODS

A retrospective review of cataract surgery undertaken in all eye health facilities in Imo State in 2019. Data collected included the type and location of facilities, patient demographics and the number and type of cataract operations performed in each facility. The CSR was calculated overall, in men and women, and in younger and older women.

RESULTS

The CSR overall was 330/million and was slightly higher in women (347/million) than in men (315/million) (p<0.001). More elderly women (≥65 years) accessed cataract surgery through outreach than men and younger women (OR 1.5 (95% CI 1.03 to 2.22, p=0.03) and 1.6 (95% CI 1.07 to 2.44, p=0.02)), respectively.

CONCLUSION

The overall CSR in Imo state was approximately one-third of that recommended for sub-Saharan Africa. Although the CSR was higher in women than in men, considerably higher CSRs are needed in women to address their higher burden of cataract blindness. Operational and intervention science research are needed, to identify and evaluate interventions which address demand and supply barriers to accessing cataract surgery, particularly for elderly women.

Prevalence and causes of blindness and visual impairment in Kogi state, Nigeria-Findings from a Rapid assessment of avoidable blindness survey

PURPOSE

To determine the prevalence and causes of blindness and visual impairment among adults in Kogi, Nigeria.

METHODS

A Rapid assessment of avoidable blindness (RAAB) protocol was used with additional tools measuring disability and household wealth to measure the prevalence of blindness and visual impairment (VI) and associations with sex, disability, wealth, cataract surgical coverage and its effectiveness.

RESULTS

Age- and sex-adjusted all-cause prevalence of bilateral blindness was 3.6% (95%CI 3.0-4.2%), prevalence of blindness among people living with additional, non-visual disabilities was 38.3% (95% CI 29.0-48.6%) compared to 1.6% (95%CI 1.2-2.1%; [Formula: see text] = 771.9, p<0.001) among people without additional disabilities. Cataract was the principal cause of bilateral blindness (55.3%). Cataract surgical coverage (CSC) at visual acuity (VA) 3/60 was 48.0%, higher among men than women (53.7% vs 40.3%); 12.0% among people with non-visual disabilities; 66.9% among people without non-visual disabilities, being higher among people in the wealthiest two quintiles (41.1%) compared to the lowest three (24.3%). Effective Cataract Surgical Coverage at Visual Acuity 6/60 was 31.0%, higher among males (34.9%) than females (25.5%), low among people with additional, non-visual disabilities (1.9%) compared to people with no additional disabilities (46.2%). Effective CDC was higher among people in the wealthiest two quintiles (411%) compared to the poorest three (24.3%). Good surgical outcome (VA>6/18) was seen in 61 eyes (52.6%) increasing to 71 (61.2%) eyes with best correction. Cost was identified as the main barrier to surgery.

CONCLUSION

Findings suggest there exists inequalities in eye care with women, poorer people and people with disabilities having a lower Cataract Surgical Coverage, thereby, underscoring the importance of eye care programs to address these inequalities.

Decline in unmet needs for cataract surgery among the ageing population in India: findings from LASI, wave-1

Introduction

Cataracts are the leading cause of blindness among older people, but they can be treated with corrective surgery. India boasts the oldest blindness control programme in the world. We aimed to assess the prevalence of cataract surgery, and we compared the determinants of undergoing cataract surgery and identified the unmet needs for cataract surgery among older adults in India.

Methods

We included 52,380 individuals aged ≥50 years from the Longitudinal Ageing Study in India, wave-1. The primary outcome measures of our study were the prevalence of cataract surgery and the unmet need for cataract surgery. Multivariate analysis was executed to investigate the association between socio-demographic variables and outcomes, expressing the results as adjusted odds ratios with 95% confidence intervals (CIs).

Results

The overall prevalence of cataracts was 14.85%. The coverage of cataract surgery was 76.95%, with 23% having unmet needs for cataract surgery. Notably, cataract surgery coverage was higher at 78.30% (95% CI: 76.88-79.48) among participants aged 66-80 years, while the percentage of those who did not undergo cataract surgery was higher at 24.62% (95% CI: 23.09-26.20) among participants aged 50-60 years. The most deprived group had a higher odds ratio [adjusted odds ratio: 1.20 (95% CI: 1.00-1.44)] (p < 0.05) of having unmet needs for cataract surgery.

Conclusions

There is a considerable burden of age-related cataracts in India. While the coverage of cataract surgery is high, the unmet need for cataract surgery cannot be overlooked. The existing blindness control programme has contributed significantly to increasing the coverage of cataract surgery, but it still needs to be strengthened, especially to reach the most deprived sections of society.

Alternative community-led intervention to improve uptake of cataract surgery services in rural Tanzania-The Dodoma Community Cataract Acceptance Trial (DoCCAT): a protocol for intervention co-designing and implementation in a cluster-randomized controlled trial

Age-related lens opacification (cataract) remains the leading cause of visual impairment and blindness worldwide. In low- and middle-income countries, utilization of cataract surgical services is often limited despite community-based outreach programmes. Community-led research, whereby researchers and community members collaboratively co-design intervention is an approach that ensures the interventions are locally relevant and that their implementation is feasible and socially accepted in the targeted contexts. Community-led interventions have the potential to increase cataract surgery uptake if done appropriately. In this study, once the intervention is co-designed it will be implemented through a cluster-randomized controlled trial (cRCT) with ward as a unit of randomization. This study will utilise both the qualitative methods for co-designing the intervention and the quantitative methods for effective assessment of the developed community-led intervention through a cRCT in 80 rural wards of Dodoma region, Tanzania (40 Intervention). The 'intervention package' will be developed through participatory community meetings and ongoing evaluation and modification of the intervention based on its impact on service utilization. Leask's four stages of intervention co-creation will guide the development within Rifkin's CHOICE framework. The primary outcomes are two: the number of patients attending eye disease screening camps, and the number of patients accepting cataract surgery. NVivo version 12 will be used for qualitative data analysis and Stata version 12 for quantitative data. Independent and paired t-tests will be performed to make comparisons between and within groups. P-values less than 0.05 will be considered statistically significant.

Real-world visual outcomes of cataract surgery based on population-based studies: a systematic review

BACKGROUND/AIMS

Quantity of cataract surgery has long been an important public health indicator to assess health accessibility, however the quality of care has been less investigated. We aimed to summarise the up-to-date evidences to assess the real-world visual outcomes after cataract surgery in different settings.

METHODS

A systematic review was undertaken in October 2021. Population-based cross-sectional and longitudinal studies reporting vision-related outcomes after cataract surgery published from 2006 onward were included. A meta-analysis was not planned.

RESULTS

Twenty-six cross-sectional studies from low-income and middle-income countries (LMICs) and five cross-sectional studies from high-income countries (HICs) were included. The proportions of participants with postoperative presenting visual acuity (VA) ≥0.32 (20/60) were all over 70% in all HICS studies, but mostly below 70% in LMICS studies, ranging from 29.9% to 80.5%. Significant difference in postoperative VA was also observed within countries. The leading causes for postoperative visual impairment (defined mostly as presenting VA <20/60) mainly included refractive error, ocular comorbidities and surgical complications including posterior capsule opacification, except for one study in Nigeria wherein the leading cause was aphakia. Only four population-based cohort studies were included with 5-20 years of follow-up time, generally demonstrating no significant changes in postoperative visual outcomes during the follow-up.

CONCLUSIONS

We observed large inequality in the visual outcomes and principal causes of visual impairment after cataract surgery among different countries and regions. Structured quality control and enhancement programmes are needed to improve the outcomes of cataract surgery and reduce inequality.

Retrospective analysis of cataract surgery outcomes in China from 2009 to 2018: from a national registry system data

OBJECTIVE

To evaluate patients' benefits after cataract surgery and to form recommendations for Chinese national health policy decision makers and administration departments based on the quality of cataract treatments.

METHOD

An observational study based on real-world data source from the National Cataract Recovery Surgery Information Registration and Reporting System.

RESULTS

A total of 14 157 463 original records were reported from 1 July 2009 to 31 December 2018. The factors that influenced the 3-day postsurgical best-corrected visual acuity (BCVA), the primary outcome, were analysed by logistic regression analysis. We found that a history of hypertension (OR=0.916) or diabetes (OR=0.912), presurgical pupil abnormality (OR=0.571) and high intraocular pressure (OR=0.578) were harmful to the postsurgical BCVA improvement (BCVA ≥6/20), while male sex (OR=1.113), better presurgical BCVA level (OR=5.996 for ≥6/12-<6/7.5 and OR=2.610 for >6/60-<6/12 taken ≤6/60 as reference), age-related cataract (OR=1.825) and intraocular lens implantation (OR=1.886) were statistically beneficial to the postsurgical BCVA improvement. Compared with extracapsular cataract extraction (ECCE) with large incision, the ECCE with small incision (OR value=1.810) and the phacoemulsification (OR=1.420) significantly improved the benefit probability.

CONCLUSION

ECCE with small incision has comparable effects on postsurgical BCVA improvement of phacoemulsification. Therefore, ECCE could be an alternative cataract surgical treatment in economically underdeveloped areas in China, provided the surgeons are adequately trained.

Cataract services for all: Strategies for equitable access from a global modified Delphi process

Vision loss from cataract is unequally distributed, and there is very little evidence on how to overcome this inequity. This project aimed to engage multiple stakeholder groups to identify and prioritise (1) delivery strategies that improve access to cataract services for under-served groups and (2) population groups to target with these strategies across world regions. We recruited panellists knowledgeable about cataract services from eight world regions to complete a two-round online modified Delphi process. In Round 1, panellists answered open-ended questions about strategies to improve access to screening and surgery for cataract, and which population groups to target with these strategies. In Round 2, panellists ranked the strategies and groups to arrive at the final lists regionally and globally. 183 people completed both rounds (46% women). In total, 22 distinct population groups were identified. At the global level the priority groups for improving access to cataract services were people in rural/remote areas, with low socioeconomic status and low social support. South Asia and Sub-Saharan Africa were the only regions in which panellists ranked women in the top 5 priority groups. Panellists identified 16 and 19 discreet strategies to improve access to screening and surgical services, respectively. These mostly addressed health system/supply side factors, including policy, human resources, financing and service delivery. We believe these results can serve eye health decision-makers, researchers and funders as a starting point for coordinated action to improve access to cataract services, particularly among population groups who have historically been left behind.

Cataract Surgery in Low-Income Countries: A Good Deal!

Cataract is a major cause of blindness worldwide. In particular, in low-income countries, the burden of disease as well as its direct and indirect economic cost are a major challenge for the population and economy. In many cases, it would be possible to prevent or cure blindness with a comparably simple cataract surgery, but many countries lack the resources to strengthen healthcare systems and implement broad cataract surgery programs reaching, in particular, the rural poor. In this paper, we analyse whether such an intervention could be cost-effective or even cost-saving for the respective health systems. We calculate the net value of the lifelong costs of cataract with and without surgery. This calculation includes direct costs (e.g., treatment, glasses, surgery) as well as indirect cost of the caregiver and the patient. We total all costs from the year of onset of cataract until death and discount the respective values to the year of onset. We define the surgery as cost-saving if the net-value of costs with surgery is lower than without surgery. If the cost per quality adjusted life year is lower than one gross national product per capita, we define the intervention as highly cost-effective. We find that the cost-effectiveness of cataract surgery depends on the age of onset of the disease and the age of surgery. If the surgery is performed with the beginning of severe impairment, even surgery of a 78-year-old patient is still cost-saving. Almost all possible constellations are highly cost-effective, only for the very old it is questionable whether the surgery should be performed. The simulations show that cataract surgery is one of the most cost-effective interventions. However, millions of people in low-income countries still have no chance to prevent or cure blindness due to limited resources. The findings of this paper clearly call for a stronger effort to reach poor and rural populations with this cost-effective service.

Effective cataract surgical coverage in adults aged 50 years and older: estimates from population-based surveys in 55 countries

BACKGROUND

Cataract is the leading cause of blindness globally. Effective cataract surgical coverage (eCSC) measures the number of people in a population who have been operated on for cataract, and had a good outcome, as a proportion of all people operated on or requiring surgery. Therefore, eCSC describes service access (ie, cataract surgical coverage, [CSC]) adjusted for quality. The 74th World Health Assembly endorsed a global target for eCSC of a 30-percentage point increase by 2030. To enable monitoring of progress towards this target, we analysed Rapid Assessment of Avoidable Blindness (RAAB) survey data to establish baseline estimates of eCSC and CSC.

METHODS

In this secondary analysis, we used data from 148 RAAB surveys undertaken in 55 countries (2003-21) to calculate eCSC, CSC, and the relative quality gap (% difference between eCSC and CSC). Eligible studies were any version of the RAAB survey conducted since 2000 with individual participant survey data and census population data for people aged 50 years or older in the sampling area and permission from the study's principal investigator for use of data. We compared median eCSC between WHO regions and World Bank income strata and calculated the pooled risk difference and risk ratio comparing eCSC in men and women.

FINDINGS

Country eCSC estimates ranged from 3·8% (95% CI 2·1-5·5) in Guinea Bissau, 2010, to 70·3% (95% CI 65·8-74·9) in Hungary, 2015, and the relative quality gap from 10·8% (CSC: 65·7%, eCSC: 58·6%) in Argentina, 2013, to 73·4% (CSC: 14·3%, eCSC: 3·8%) in Guinea Bissau, 2010. Median eCSC was highest among high-income countries (60·5% [IQR 55·6-65·4]; n=2 surveys; 2011-15) and lowest among low-income countries (14·8%; [IQR 8·3-20·7]; n=14 surveys; 2005-21). eCSC was higher in men than women (148 studies pooled risk difference 3·2% [95% CI 2·3-4·1] and pooled risk ratio of 1·20 [95% CI 1·15-1·25]).

INTERPRETATION

eCSC varies widely between countries, increases with greater income level, and is higher in men. In pursuit of 2030 targets, many countries, particularly in lower-resource settings, should emphasise quality improvement before increasing access to surgery. Equity must be embedded in efforts to improve access to surgery, with a focus on underserved groups.

FUNDING

Indigo Trust, Peek Vision, and Wellcome Trust.

Assessing the capacity of primary health care facilities in Nigeria to deliver eye health promotion: Results of a mixed-methods feasibility study

Over 25 million people in sub-Saharan Africa are blind or visually impaired, the majority from avoidable causes. Health promotion and disease prevention are important strategies for eye health, through good governance, health literacy and increasing access to eye care services. To increase equity in access for eyecare services, the World Health Organization Africa Region developed a package of interventions for primary eye care, which includes health promotion. The aim of this study was to assess the capacity of the primary healthcare system to deliver health promotion for eye care in Nigeria. Mixed methods were used during a survey of 48 government-owned primary health care facilities in Anambra state, Nigeria: interviews with district health supervisors, facility staff and village health workers, and a desk review of policy documents for primary health care and eye care in Nigeria. Findings were benchmarked against the capacities needed to deliver health promotion agreed through a Delphi exercise and were analysed using the World Health Organization's health system building blocks. Eye health promotion policies exist but are fragmented across different national health policies. Health promotion activities focussed on "mobilising" community members to access care provided in facilities, particularly for women of childbearing age and young children, and health education was limited. Only one in ten facilities engaged the elderly and a fifth delivered health promotion for eye care. Health promotion activities were supervised in 43.2% of facilities and transport to remote areas was limited. A robust eye health promotion strategy needs to be included in the National Eye Health Policy. The scope of existing health promotion will need to expand to include eye conditions and different age groups. Increasing eye health literacy should be emphasized. Governance, training health workers in eye health promotion, educational materials, and transport to visit communities will also be needed.

Measuring equity of access to eye health outreach camps in rural Malawi

Introduction

Equity in the access and use of health services is critical if countries are to make progress towards universal health coverage and address the systematic exclusion of the most vulnerable groups. The purpose of this study was to assess if the Co-ordinated Approach To Community Health programme implemented by Sightsavers was successful in reaching the poorest population, women, and people living with disabilities in Kasungu district, Malawi.

Methods

Between April and September 2017, data on socio-economic status, household characteristics and functional disability were collected from patients attending at eye camps in Kasungu district, Malawi. Using asset-based tools to measure household wealth (EquityTool© and Simple Poverty Scorecard©) and the Washington Group Short Set of Questions, individuals were categorised by wealth quintiles, poverty status, and functional disability status and then compared to relevant representative national household surveys. In addition, a follow-up household survey was conducted to check the validity of self-reported household characteristics at eye camps.

Results

A total of 1,358 individuals participated in the study. The study shows that self-reported data on household characteristics and assets are reliable and can be collected in clinical settings (instead of relying on direct observations of assets). Individuals attending outreach camps were poorer in terms of relative wealth and absolute poverty rates compared to the rest of the population in Kasungu. It was estimated that 9% of the participants belonged to the poorest quintile compared to 4% for the population in Kasungu (DHS 2015–2016). The ultra-poverty rate was also lower among respondents (13%) compared to 15% for Kasungu district (IHS 2017). The functional disability rate was 27.5% for study participants, and statistically higher than the general population (5.6%, SENTIF 2017). Even though women are more at risks than men, 54% of the participants were men.

Conclusions

Our study shows that existing tools can be reliably used, and combined, if based on recent population data, to assess equity of access to health services for vulnerable groups of the population. The findings suggest that the programme was successful in reaching the poorest people of the Kasungu district population as well as those with disabilities through outreach camps but that more men than women were reach through the programme. Subsequently, our study showed that self-reported household characteristics are a reliable method to measure asset-based wealth of camps’ attendee. However, it is essential to use sub-national data (district or regional level) from recent surveys for the purpose of benchmarking in order to produce accurate results.

Evidence on cataract in low- and middle-income countries: an updated review of reviews using the evidence gap maps approach

In 2014, Sightsavers developed the first evidence gap map (EGM) to assess the extent and quality of review-level evidence on cataract relevant to low-and middle-income countries. The EGM identified 52 studies across five broad themes. This paper reports the update of the EGM conducted in 2021 and changes to the extent and quality of the evidence base. We updated the EGM using the exact process conducted to develop the original. Searches were run to 14 September 2021, and two independent reviewers selected eligible studies, critically appraised them and extracted data using the Supporting the Use of Research Evidence checklist. A summary quality assessment was shared with the authors for comments. Forty-six new reviews were identified, and the EGM now includes 98 reviews. The new reviews predominantly focus on treatment and risk factors. The overall methodological quality was found to be improved, with 13/46 reporting high confidence in findings. EGMs remain a useful tool for policy-makers to make informed decisions and periodic updates are important to assess changes and to refine the focus for future research. The EGM highlights significant disparity in the topics addressed by reviews, with health system interventions particularly neglected.

Prevalence of the Burden of Diseases Causing Visual Impairment and Blindness in South Africa in the Period 2010-2020: A Systematic Scoping Review and Meta-Analysis

The prevalence of visual impairment (VI) continues to rise, despite efforts to reduce it. The burden of disease negatively impacts the quality of life, education opportunities, and other developments in various communities. Henceforth, this study aimed to determine and quantify the major causes of VI in South Africa, to ensure accurate interventions in addressing them and to reduce the burden of ocular disease in that context. A systematic scoping review was conducted to map evidence on VI and ocular diseases, using the PRISMA-P guidelines. English studies were searched for on PubMed, Google Scholar, and EBSCOhost using various search terms. The eligible articles underwent screening and ultimately data extraction to identify major causes of VI in South Africa. A meta-analysis further resulted in pooled prevalence estimates (PPE) using the Inverse Variance Heterogeneity (IVhet) model. Of the 13,527 studies screened at three levels, 10 studies met the inclusion criteria for the final review; however, 9 studies were eligible for quality assessment performed by two independent reviewers. The quality index for the included studies was 71.1%. The prevalence of VI was 2% for blindness and 12% for moderate and severe visual impairment (MSVI). Pooled prevalence identified uncorrected refractive error (URE) (43%), cataract (28%), glaucoma (7%), and diabetic retinopathy (4%) as major causes of MSVI. The leading causes of blindness were untreated cataracts (54%), glaucoma (17%), and diabetic retinopathy (57%). Ocular diseases causing VI are avoidable and similar to those of low-to-middle income countries. MSVI were caused by URE, cataract, glaucoma, and diabetic retinopathy. Blindness was mainly caused by cataracts, glaucoma, and diabetic retinopathy. A strategic plan to manage these conditions would largely reduce the burden of VI in the country. Early screenings and interventions to maximize care at primary health levels would decrease the burden of avoidable blindness in the country significantly.

Knowledge, Attitudes and Practices of Eye Health among Public Sector Eye Health Workers in South Africa

In South Africa, primary eye care is largely challenged in its organisational structure, availability of human and other resources, and clinical competency. These do meet the standard required by the National Department of Health. This study seeks to assess the levels of knowledge, attitudes, and practices on eye health amongst Human Resources for eye health (HReH) and their managers, as no study has assessed this previously. A cross-sectional study was conducted in 11 districts of a South African province. A total of 101 participants completed self-administered, close-ended, Likert-scaled questionnaires anonymously. Binary logistic regression analysis was conducted, and values of p < 0.05 were considered statistically significant. Most participants had adequate knowledge (81.6%), positive attitudes (69%), and satisfactory practices (73%) in eye health. HReH showed better knowledge than their managers (p < 0.01). Participants with a university degree, those aged 30-44 years, and those employed for <5 years showed a good attitude (p < 0.05) towards their work. Managers, who supervise and plan for eye health, were 99% less likely to practice adequately in eye health when compared with HReH (aOR = 0.012; p < 0.01). Practices in eye health were best amongst participants with an undergraduate degree, those aged 30-44 years (aOR = 2.603; p < 0.05), and participants with <5 years of employment (aOR = 26.600; p < 0.01). Knowledge, attitudes, and practices were found to be significantly moderately correlated with each other (p < 0.05). Eye health managers have poorer knowledge and practices of eye health than the HReH. A lack of direction is presented by the lack of adequately trained directorates for eye health. It is therefore recommended that policymakers review appointment requirements to ensure that adequately trained and qualified directorates be appointed to manage eye health in each district.

Financing of surgery and anaesthesia in sub-Saharan Africa: a scoping review

OBJECTIVE

This study aimed to provide an overview of current knowledge and situational analysis of financing of surgery and anaesthesia across sub-Saharan Africa (SSA).

SETTING

Surgical and anaesthesia services across all levels of care-primary, secondary and tertiary.

DESIGN

We performed a scoping review of scientific databases (PubMed, EMBASE, Global Health and African Index Medicus), grey literature and websites of development organisations. Screening and data extraction were conducted by two independent reviewers and abstracted data were summarised using thematic narrative synthesis per the financing domains: mobilisation, pooling and purchasing.

RESULTS

The search resulted in 5533 unique articles among which 149 met the inclusion criteria: 132 were related to mobilisation, 17 to pooling and 5 to purchasing. Neglect of surgery in national health priorities is widespread in SSA, and no report was found on national level surgical expenditures or budgetary allocations. Financial protection mechanisms are weak or non-existent; poor patients often forego care or face financial catastrophes in seeking care, even in the context of universal public financing (free care) initiatives.

CONCLUSION

Financing of surgical and anaesthesia care in SSA is as poor as it is underinvestigated, calling for increased national prioritisation and tracking of surgical funding. Improving availability, accessibility and affordability of surgical and anaesthesia care require comprehensive and inclusive policy formulations.

How can we improve the quality of cataract services for all? A global scoping review

BACKGROUND

Cataract is a leading cause of blindness and vision impairment globally. Cataract surgery is one of the most frequently performed operations worldwide, but good quality services are not universally available. This scoping review aims to summarise the nature and extent of published literature on interventions to improve the quality of services for age-related cataract globally.

METHODS

We used the dimensions of quality adopted by WHO-effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency-to which we added planetary health. On 17 November 2019, we searched MEDLINE, Embase and Global Health for manuscripts published since 1990, without language or geographic restrictions. We included studies that reported quality-relevant interventions and excluded studies focused on technical aspects of surgery or that only involved children (younger than 18 years). Screening of titles/abstracts, full-text review and data extraction were performed by two reviewers independently. Studies were grouped thematically and results synthesised narratively.

RESULTS

Most of the 143 included studies were undertaken in high-income countries (n = 93, 65%); 29 intervention groups were identified, most commonly preoperative education (n = 17, 12%) and pain/anxiety management (n = 16, 11%). Efficiency was the quality element most often assessed (n = 58, 41%) followed by people-centredness (n = 40, 28%), while integration (n = 4) and timeliness (n = 3) were infrequently reported, and no study reported outcomes related to planetary health.

CONCLUSION

Evidence on interventions to improve quality of cataract services shows unequal regional distribution. There is an urgent need for more evidence relevant to low- and middle-income countries as well as across all quality elements, including planetary health.

Eye Health Service Uptake among People with Visual Impairment and Other Functional Difficulties in Bangladesh: A Cross-Sectional Study with Short-Term Follow Up

People with visual impairments are disproportionately likely to also have other impairments. However, little is known about whether these other impairments affect access to eye health services. This study among cataract and refractive error patients in four districts in Bangladesh explores the relationship between self-reported difficulties in hearing, mobility, self-care, communication and cognition domains, eye health service uptake, and location of initial eye health assessment. Cataract and refractive errors were diagnosed through ophthalmic clinical assessment, and the Washington Group Short Set (WG-SS) was used to ascertain difficulties in other functional domains. Univariate and multivariate analyses were used to examine the relationship between functional difficulties and uptake of cataract and refractive error services. We found that people with self-reported functional difficulties were less likely to take up refractive error services compared to people with same need but with no functional difficulties, and that they were more than twice as likely to access surgical services after attending an outreach camp compared with a hospital facility. Since a high proportion of people attending eye health assessment services have difficulties in a range of functional domains, strategies to improve the uptake of hospital-based health services are urgently required.

Decomposition of Economic Inequality in Cataract Surgery Using Oaxaca Blinder Decomposition: Tehran Geriatric Eye Study (TGES)

Purpose: The aim of this study was to investigate economic inequality in cataract surgery and to decompose it into its determinants using Oaxaca-Blinder decomposition.Methods: The Tehran Geriatric Eye Study is a population-based cross-sjal study that was done on individuals above 60 years using stratified cluster random sampling. All subjects underwent full optometric, slit lamp, and fundoscopic examinations. Then, after pupil dilation, the history of cataract surgery, including PC and AC IOL, was determined.Results: The age and sex-standardized prevalence of cataract surgery was 33.51% (95% CI: 31.45 to 35.62). Cataract surgery had a significant positive association with age (OR: 14.06; p < .001 for >80 vs 60-64 years) and a significant inverse association with education level (OR: 0.55, p: 0.006 for college education vs being illiterate) and economic status (OR: 0.64, p: 0.003 for rich vs poor). A significant difference was found in cataract surgery between the rich and poor (26.22%) disfavoring the poor (p < .001). The explained and unexplained portions comprised 95.99% and 4.01% of the difference (p < .001 and p = .336, respectively). Among study variables, age (p < .001), education (p = .003), economic status (p = .002), insurance (p = .011), and eye examination (p < .001) were significant determinants of inequality in the explained portion.Conclusion: There was a marked difference in the prevalence of cataract surgery between the rich and poor that was mostly caused by the explained portion. Age, economic status, and education had the largest effects on increasing the inequality and history of eye examination by an ophthalmologist and insurance coverage had the largest effects on reducing this inequality.

What factors affect patients' ability to access healthcare? An overview of systematic reviews

OBJECTIVES

This overview aims to synthesise global evidence on factors affecting healthcare access, and variations across low- and middle-income countries (LMICs) vs. high-income countries (HICs); to develop understanding of where barriers to healthcare access lie, and in what context, to inform tailored policies aimed at improving access to healthcare for all who need it.

METHODS

An overview of systematic reviews guided by a published protocol was conducted. Medline, Embase, Global Health and Cochrane Systematic Reviews databases were searched for published articles. Additional searches were conducted on the Gates Foundation, WHO and World Bank websites. Study characteristics and findings (barriers and facilitators to healthcare access) were documented and summarised. The methodological quality of included studies was assessed using an adapted version of the AMSTAR 2 tool.

RESULTS

Fifty-eight articles were included, 23 presenting findings from LMICs and 35 presenting findings from HICs. While many barriers to healthcare access occur in HICs as well as LMICs, the way they are experienced is quite different. In HICs, there is a much greater emphasis on patient experience; as compared to the physical absence of care in LMICs.

CONCLUSIONS

As countries move towards universal healthcare access, evaluation methods that account for health system and wider cultural factors that impact capacity to provide care, healthcare finance systems and the socio-cultural environment of the setting are required. Consequently, methods employed in HICs may not be appropriate in LMICs due to the stark differences in these areas.

The Rising Burden of Diabetes-Related Blindness: A Case for Integration of Primary Eye Care into Primary Health Care in Eswatini

There is a rampant increase in diabetes prevalence globally. Sub-Saharan Africa (SSA) is projected to carry the largest burden of diabetes (34.2 million) by 2030. This will inevitably cause a parallel increase in diabetes-associated complications; with the predominant complications being blindness due to diabetic retinopathy and diabetic cataracts. Eye programs in developing countries remain inadequate, existing as stand-alone programs, focused on the provision of acute symptomatic care at secondary and tertiary health levels. Over 60% of people with undiagnosed diabetes report to eye care facilities with already advanced retinopathy. While vision loss due to cataracts is reversible, loss of vision from diabetic retinopathy is irreversible. Developing countries have in the last two decades been significantly impacted by infectious pandemics; with SSA countries committing over 80% of their health budgets towards infectious diseases. Consequently, non-communicable diseases and eye health have been neglected. This paper aimed to highlight the importance of strengthening primary health care services to prevent diabetes-related blindness. In SSA, where economies are strained by infectious disease, the projected rise in diabetes prevalence calls for an urgent need to reorganize health systems to focus on life-long preventative and integrated measures. However, research is critical in determining how best to integrate these without further weakening health systems.

Public Interest in Cataract Surgery: Analysis and Implications of Google Trends Data from 14 European Countries

Purpose: Cataract surgery is the most common surgery performed in the European Union (EU) annually. Analysis of Google Trends (GT) data could give European eye care providers useful information regarding interest in cataract surgery and potential barriers making patients unwilling to undergo surgery.Methods: Data were collected using GT for cataract surgery and the two most related queries, for each of 14 included countries from January 2004 to December 2018. Case volumes were extracted from the Eurostat report for the calendar years 2004-2018.Results: The most related queries analysis demonstrated surgery outcomes, founding issues and understanding of the disease as potential factors for patients considering cataract surgery. Trend analysis showed that the total search volumes for "cataract surgery" gradually increased over the study period. Also, for "cataract", "after cataract surgery", "cataract surgery NHF" rising trends were revealed. Trends found for "cataract surgery price" and "cataract surgery complications" were inconclusive. Univariate linear regression analysis demonstrated statistically significant correlations between average annual search volumes of "cataract surgery" and the annual volume of cataract surgeries performed in included countries, according to Eurostat data (R² = 0.889, p = <.001). In addition, univariate linear regression analyses revealed similar, statistically significant correlation for each the most related queries.Conclusions: To the knowledge of the authors, this is the first and the only analysis of GT data in the ophthalmology literature to date. This study highlights this potentially powerful data set for European eye care providers.

The Appointment System Influences Uptake of Cataract Surgical Services in Rwanda

The aim of this study was to investigate barriers and enablers associated with the uptake of cataract surgery in Rwanda, where financial protection is almost universally available. This was a hospital-based cross-sectional study where potential participants were adults aged >18 years who accepted an appointment for cataract surgery during the study period (May–July 2019). Information was collected from hospital records and a semi-structured questionnaire was used for data collection. Of the 297 people with surgery appointments, 221 (74.4%) were recruited into the study, 126 (57.0%) of whom had attended their appointment. People more likely to attend their surgical appointment were literate, had fewer than 8 children, had poorer visual acuity, had access to a telephone in the family, received a specific date to attend their appointment, received a reminder, and reported no difficulties walking (95% significance level, p < 0.05). The most commonly reported barriers were insufficient information about the appointment (n = 40/68, 58.8%) and prohibitive indirect costs (n = 29/68, 42.6%). This study suggests that clear communication of appointment information and a subsequent reminder, together with additional support for people with limited mobility, are strategies that could improve uptake of cataract surgery in Rwanda.

Mobile health intervention for promotion of eye health literacy

PURPOSE

Improving eye health awareness in the underserved population is a universal eye health priority. The ubiquity of cell phones and internet usage provides new and innovative opportunities for health promotion. This study evaluated the effect of mobile health intervention (text message link) to promote eye health literacy (EHL) of priority ocular morbidities.

METHODS

This study was an intervention evaluation and employed a two-armed pre-test post-test approach. Baseline assessment on EHL was performed on 424 university students. Participants were categorised into intervention and control groups, using the 1:1 allocation ratio. The intervention and control group received a text message alone and text message with a link, respectively. EHL was assessed via a self-administered questionnaire. The primary outcome measures were changes in EHL scores between baseline and one month post-intervention. Descriptive analysis was performed to assess the cost-effectiveness of the intervention.

RESULTS

With low attrition and a response rate of 95.6%, 409 responses were eligible for analysis. The mean age of the participants (49.4% males and 50.6% of females) was 19.9±1.68 years. Baseline EHL scores were low, and there was no correlation with a demographic profile (all p<0.05, CI 95%). The demographic characteristics were similar between the two groups (for all, P <0.05, CI 95%) at baseline. The EHL scores improved in both groups between the pre-and post-test assessment; however, improvements were statistically significant only in the control group. The one-month post-intervention EHL scores were also higher in the intervention group compared to the control (p≤0.001, CI 95% for all). The total cost incurred for the intervention used was 11.5 USD.

CONCLUSION

Text message link demonstrated effectiveness for improving the EHL scores; the low baseline EHL scores substantially improved with intervention. The text message link intervention is a cost-effective method and could be considered in advocating for eye health in developing countries, particularly during global emergencies.

Artificial intelligence in global ophthalmology: using machine learning to improve cataract surgery outcomes at Ethiopian outreaches

Differences between target and implanted intraocular lens (IOL) power in Ethiopian cataract outreach campaigns were evaluated, and machine learning (ML) was applied to optimize the IOL inventory and minimize avoidable refractive error. Patients from Ethiopian cataract campaigns with available target and implanted IOL records were identified, and the diopter difference between the two was measured. Gradient descent (an ML algorithm) was used to generate an optimal IOL inventory, and we measured the models performance across varying surplus levels. Only 45.6% of patients received their target IOL power and 23.6% received underpowered IOLs with current inventory (50% surplus). The ML-generated IOL inventory ensured that more than 99.5% of patients received their target IOL when using only 39% IOL surplus. In Ethiopian cataract campaigns, most patients have avoidable postoperative refractive error secondary to suboptimal IOL inventory. Optimizing the IOL inventory using this ML model might eliminate refractive error from insufficient inventory and reduce costs.

Blindness and Visual Impairment Situation in Indonesia Based on Rapid Assessment of Avoidable Blindness Surveys in 15 Provinces

Purpose: To report the latest data on blindness and visual impairment (VI) in Indonesia.Methods: Rapid Assessment of Avoidable Blindness (RAAB) surveys were done in 15 provinces in Indonesia between 2013 and 2017. The population of the study was people aged 50 +. In each province, the required number of clusters was selected with a probability proportionately to size. A weighted average analysis for prevalence, causes of visual impairment, and cataract surgical coverage (CSC) estimated the values of the country.Results: The prevalence of blindness in East Java was the highest at 4.4% (95% CI: 3.1-5.6%), followed by Nusa Tenggara Barat (NTB) at 4.0% (95% CI: 3.0-5.1%) and South Sumatra at 3.4% (95% CI: 2.4-4.4%). In number, blindness among people aged 50+ in East Java was the highest at 371,599, followed by West Java at 180,666 and Central Java at 176,977. Untreated cataract was the commonest cause of blindness in all provinces (range: 71.7% to 95.5%). CSC_person<3/60 and CSC_person<6/60 in Bali were the highest at 81.3% and 72.4%, respectively. Indonesia countrywide prevalence of blindness was 3.0%. The total number of people with VI (PVA less than 6/18 in the better eye) in Indonesia was 8,019,427, consisting of 1,654,595 of blindness and 6,364,832 of moderate and severe VI.Conclusion: The burden of blindness in Indonesia is high, and untreated cataract contributes the most. There is an urgent need to increase cataract surgical coverage by providing better access to cataract surgery services for all people in need.

Prevalence, care-seeking practices and impact of self-reported vision impairment in Southwest Cameroon: a community-based study

OBJECTIVES

To establish the prevalence of self-reported vision impairment (VI) in Southwest Cameroon and describe associated care-seeking practices, functional limitations and economic hardships.

DESIGN

A three-stage clustered sampling household community-based survey.

SETTING

The Southwest region of Cameroon.

PARTICIPANTS

8046 individuals of all ages residing in the Southwest region of Cameroon.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of self-reported VI, onset of vision loss, care-seeking practices, diagnosis and treatment, functional limitations, economic hardships on household, beliefs about surgical treatability of blindness and barriers to surgical care.

RESULTS

The estimated prevalence of self-reported VI in Southwest Cameroon was 0.87% (95% CI 0.62 to 1.21). Among participants aged ≥40 years, the prevalence increased to 2.61% (95% CI 1.74 to 3.90). Less than a quarter of affected participants reported difficulty working (20.5%) or trouble going to school (12.0%) as a result of their VI. Yet, over half (52%, n=43) of affected households experienced significant economic hardships due to the VI. Residing in an urban setting (aOR 1.16, 95% CI 1.04 to 1.30) and belonging to a higher socioeconomic status (aOR 1.13, 95% CI 1.02 to 1.26) were factors associated with the belief that certain types of blindness were surgically reversible. Formal care was not sought by 16.3% (n=8) of affected participants. Cataracts was the leading diagnosis among participants who did seek formal care (43.2%, n=16), although 93.8% of these cases were not surgically treated, primarily due to a lack of perceived need.

CONCLUSION

The prevalence of individuals who report vision impairment in Southwest Cameroon is considerably lower than prior published estimates based on visual physical examinations. Routine community-level screening and cost financing schemes could improve detection of pre-clinical eye disease and the utilisation of surgical care. It could also pre-empt disability and economic hardships associated with advanced VI in the region.

Cataract surgery in surgical camps: outcomes in a rural area of Cameroon

AIM

To assess the complications and visual outcomes of cataract surgery during an outreach eye camp in Cameroon in which two foreign ophthalmologists operate alongside a local one.

MATERIALS AND METHODS

This is a retrospective and comparative cohort study. The patients were consecutively assigned to three groups depending on the ophthalmologist who performed the cataract surgeries. All eyes underwent manual sutureless incision cataract surgery with posterior chamber intraocular lens (PCIOL) implantation under peribulbar anesthesia. Postoperative visits were scheduled for the first day, first week and second month after the procedures. Intra- and postoperative complications, best-corrected visual acuity and also refractive errors were assessed.

RESULTS

A total of 263 eyes underwent cataract extraction with PCIOL implantation. The percentage of eyes in which two or more lines of corrected distance visual acuity decreased were 2.4%, 2.7% and 0% for groups A, B and C, respectively. The percentage of eyes with good visual outcome (uncorrected distance visual acuity UDVA > 20/60) were, respectively, 82.09%, 81.43% and 80.82% for the three groups. Similar results were found between the three groups regarding complications. Ocular hypertension, transient corneal edema and hyphema were the incidences registered at the first postoperative control performed 24 h after surgery. The most common complication observed 2 months after surgery was posterior capsular opacity (2.6%).

CONCLUSION

High-volume cataract surgery in low- and middle-income countries may have good visual outcomes and a low rate of complications when the procedures are performed by either foreign or local ophthalmologists.

SYNOPSIS

A program of high-volume cataract surgery carried out in a rural environment with few resources can give good visual outcomes in the hands of both foreign and local experienced ophthalmologists.

Factors associated with the uptake of cataract surgery and interventions to improve uptake in low- and middle-income countries: A systematic review

Despite significant evidence around barriers hindering timely access to cataract surgery in low- and middle-income countries (LMICs), little is known about the strategies necessary to overcome them and the factors associated with improved access. Despite significant evidence that certain groups, women for example, experience disproportionate difficulties in access, little is known about how to improve the situation for them. Two reviews were conducted recently: Ramke et al., 2018 reported experimental and quasi-experimental evaluations of interventions to improve access of cataract surgical services, and Mercer et al., 2019 investigated interventions to improve gender equity. The aim of this systematic review was to collate, appraise and synthesise evidence from studies on factors associated with uptake of cataract surgery and strategies to improve the uptake in LMICs. We performed a literature search of five electronic databases, google scholar and a detailed reference review. The review identified several strategies that have been suggested to improve uptake of cataract surgery including surgical awareness campaigns; use of successfully operated persons as champions; removal of patient direct and indirect costs; regular community outreach; and ensuring high quality surgeries. Our findings provide the basis for the development of a targeted combination of interventions to improve access and ensure interventions which address barriers are included in planning cataract surgical services. Future research should seek to examine the effectiveness of these strategies and identify other relevant factors associated with intervention effects.

The cost and quality of life impact of glaucoma in Tanzania: An observational study

AIMS

To determine the cost and quality of life impact imposed by glaucoma in Tanzania, East Africa.

METHODS

An expert panel of eye health professionals was convened to agree current glaucoma practice in Tanzania. In addition a structured patient survey was developed and administered. Supplemental cost and quality of life information was collected using cost questionnaires and validated quality of life measures, including the EQ5D and VFQ-25.

RESULTS

Key findings include following. Non-adherence is a major issue, especially in rural settings where over 50% of the patients may fail to return for review. Whilst medical therapy is overwhelmingly the first line treatment, the cost of maintaining this represents up to 25% of a patient's income. There is an impact of glaucoma on patients general well-being as determined by the EQ-5D and more tellingly on visual function with particular impact on role limitations as determined by the VF25. Despite our sample being taken in a private clinic and thus containing a much larger proportion of professionals than the general population, one third of the population earned Tanzanian Shillings (TZS) 170,000 per month which is below the minimum wage.

CONCLUSION

These findings are of great importance for health care planners seeking to determine cost-effective, acceptable methods of both identifying and treating this major cause of preventable blindness.

Prevalence of Visual Impairment and Coverage of Cataract Surgical Services: Associations with Sex, Disability, and Economic Status in Five Diverse Sites

PURPOSE

Prevalence of visual impairment (VI) and access to services can vary significantly across and between different population groups. With renewed focus on universal health coverage and leaving no one behind, it is important to understand factors driving inequitable eye health. This paper presents results from five population-based surveys where prevalence of VI and cataract surgical coverage (CSC) were measured and examined for differences by sex, economic-status, and disability.

METHODS

Rapid assessments of avoidable blindness took place in four rural sites: Kalahandi, Jhabua and Sitapur in India; and Singida, Tanzania; and one urban site: Lahore, Pakistan. In addition, the Equity Tool was used to measure economic status and the Washington Group Short Set was used to measure disability. Prevalence of VI and CSC were calculated and associations with sex, disability, and relative wealth examined.

RESULTS

Prevalence of VI varied from 1.9% in Lahore to 15.0% in Kalahandi. CSC varied from 39.1% in Singida to 84.0% in Lahore. Additional disability was associated with greater levels of VI in all sites and lower CSC in Singida. Being female was associated with higher VI in Kalahandi, Lahore and Singida and lower CSC in Lahore and Singida. Being poorer was associated with higher VI in Singida and lower CSC in Singida and Sitapur.

CONCLUSION

Relationships between VI and relative wealth, sex, and disability are complex and variable. Although certain characteristics may be associated with lower coverage or worse outcomes, they cannot be generalized and local data are vital to tailor services to achieve good coverage.

Equity was rarely considered in Cochrane Eyes and Vision systematic reviews and primary studies on cataract

OBJECTIVE

We sought to understand the extent to which Cochrane Eyes and Vision systematic reviews of interventions for cataract, and primary studies, consider equity.

STUDY DESIGN AND SETTING

This is a review of Cochrane Eyes and Vision systematic reviews (CSRs) on cataract published on the Cochrane Library (end of March 2019) (n = 23), and recently published primary studies included in those reviews (n = 62), using the PROGRESSPlus framework.

RESULTS

One CSR considered equity as a topic. Four (17%) CSRs included a low- and middle-income country (LMIC) author; one of them was a first author. The CSR with equity as a main topic restricted primary studies to those conducted in LMICs; otherwise none of the systematic reviews used PROGRESS factors as inclusion or exclusion criteria. None of the CSRs reported subgroup analyses by any PROGRESS factor, although these were planned in two. Two of the primary studies were led by an LMIC author; 42% involved LMIC authors; 37% were conducted in LMICs; 73% of studies reported on gender/sex of participants, but other PROGRESS factors were less frequently reported. Three studies reported subgroup analyses by sex; one reported subgroup analyses by race/ethnicity.

CONCLUSION

PROGRESS factors and equity are rarely considered in studies of interventions for cataract, and this is reflected in the associated Cochrane reviews.

Strengths and weaknesses of eye care services in sub-Saharan Africa: a meta-synthesis of eye health system assessments

BACKGROUND

In sub-Saharan Africa (SSA), the delivery of eye care services continues to be undermined by health systems performance bottlenecks. There is a growing focus by partners in the sector on the analysis of the different components of eye care within the wider health system context to diagnose and manage interactions in ways that achieve more effective improvements. However, there has been no attempt to date to systematically synthesize these studies. In this study, we conducted a meta-synthesis of eye health system assessments to gain a more comprehensive understanding of the current systems and how they can be strengthened across different SSA contexts.

METHODS

We conducted a comprehensive search for eye health system assessment reports using global and regional websites of the WHO and other organizations supporting eye care in sub-Saharan Africa. A range of online databases with no language restrictions (PubMed, EMBASE, MEDLINE, PsycINFO and CINAHL) were searched for peer-reviewed publications referring to eye health system assessment (EHSA) or eye care service assessment tool (ECSAT). Assessments were included if they used the ECSAT or EHSA tool; were conducted in sub-Saharan Africa; and had been completed with full reports available in the public domain by January 15, 2019. A combination of framework and thematic syntheses was used.

RESULTS

Our search strategies yielded a total of 12 assessments conducted in nine countries using the ECSAT/EHSA tool in Sub-Saharan Africa. Eight assessments met our inclusion criteria: four were from West Africa, two from East Africa and two from Southern Africa. Across the eight countries, findings show considerable progress and improvements in the areas of governance, organisation, financing, provision, and coverage of eye care. However, several systemwide weaknesses were found to continue to impede quality eye health service planning and delivery across the countries included in this review.

CONCLUSIONS

These findings highlight the need for national governments and iNGOs to invest in conducting and wider use of these assessments. Such analyses are particularly useful in building links between different system elements and in finding innovative, more flexible solutions and partnerships - needed to address avoidable vision loss in resource poor settings.

Horizontal inequity in the utilization of cataract surgery in Iran: Shahroud Eye Cohort Study, 2009-2014

Background: Since there was no evidence about economic inequity in utilization of cataract surgery in developing countries, such as Iran, this study was designed to measure horizontal inequity in the utilization of cataract surgery and its changes in an Iranian middleaged population in 2009 and 2014. Methods: Using data from the first and second phases of Shahroud Eye Cohort Study (2009-2014), the economic inequity in the utilization of cataract surgery in an Iranian middle-aged population aged 40-64 years in 2009 and 2014 was evaluated. The horizontal inequity index (HI) was determined using the indirect standardization method based on a nonlinear (probit) model and the concentration index (C) was decomposed into the contribution of each factor. The analyses were performed using STATA software version 12/SE, and significance level was set at less than 0.05. Results: The HI in the utilization of cataract surgery increased from 0.080 (95% CI: 0.011-0.098) in 2009 to 0.166 (95% CI: 0.0821- 0.228) in 2014. Decomposition of changes in the concentration index showed that among need and non-need variables, older age and economic status (being among the wealthiest 20%) were the greatest contributors, with shares of 67.5% and 57.5%%, respectively, which led to pro-rich inequity during the study periods. Conclusion: The present study demonstrated that utilization of cataract surgery did not have an equal distribution among economic quintiles, despite considering equal needs based on cataract severity. Results demonstrated that older age and economic status were the greatest contributors to HI increase in 2009 and 2014.

Association Between a Centrally Reimbursed Fee Schedule Policy and Access to Cataract Surgery in the Universal Coverage Scheme in Thailand

Importance

Uptake of cataract surgery in developing countries is much lower than that in developed countries. Cataract unawareness and financial barriers have been cited as the main causes. Under the Universal Coverage Scheme (UCS), Thailand introduced a central reimbursement (CR) system for cataract surgery. It is unknown if this financial arrangement could incentivize service provision (private or public) in areas that are hard to reach.

Objective

To examine the association between the CR policy and access to cataract surgery in Thailand.

Design, Setting, and Participants

Using time series analysis, hospitalization data during 2005 to 2015 for UCS members were analyzed for time trends and subnational variations in the cataract surgery rate (CSR) before and after the CR implementation.

Main Outcomes and Measures

The annual growth in access was estimated using segmented regression. The CSR gap across regions was determined by the slope index of inequality (SII). Unequal access across districts was represented by the gap between the top and bottom quintiles.

Results

During 2005 to 2015, a total of 0.98 million UCS members (mean [SD] age, 67.4 [11.2] years; 58.7% female) received cataract surgery. The number of cases increased from 77 897 in 2005 to 192 290 in 2015. At the national level, the CSR per 100 000 population increased from 352.0 to 378.7 cases in 2005 to 2008, to 716.3 cases in 2013, and then to 765.3 cases in 2015. With the use of mobile services through an exclusive CR, 3 private hospitals took the lead in service growth, sharing 79.2% of cases in the private sector in 2009. From 2010, the number of cases in public hospitals grew yearly by 12.6% to 13.6% until 2012, rose 21.7% in 2013, and then the rate of increase declined to that of 8.2% to 8.3% in 2014-2015. During the periods of an increase in overall access, the CSR gap across regions widened as indicated by the SII of 755.4 cases per 100 000 population in 2010 because of rapid uptake in areas with mobile services. When the national CSR became adequately large and mobile services were discouraged in 2013, the gap in 2014-2015 narrowed.

Conclusions and Relevance

This study found that the appropriate payment and service designs helped reduce the cataract surgery backlog. With an adequately high CSR, Thailand is on track to reach the VISION 2020 goal, aiming for blindness elimination by the year 2020, which has been achieved by most developed countries.

Association of Sex With the Global Burden of Cataract

Importance

Eye disease burden could help guide health policy making. Differences in cataract burden by sex is a major concern of reducing avoidable blindness caused by cataract.

Objective

To investigate the association of sex with the global burden of cataract by year, age, and socioeconomic status using disability-adjusted life-years (DALYs).

Design, Setting, and Participants

This international, comparative burden-of-disease study extracted the global, regional, and national sex-specific DALY numbers, crude DALY rates, and age-standardized DALY rates caused by cataract by year and age from the Global Burden of Disease Study 2015. The DALY data were collected from January 1, 1990, through December 31, 2015, for ever 5 years. The human development index (HDI) in 2015 was extracted as an indicator of national socioeconomic status from the Human Development Report.

Main Outcomes and Measures

Comparisons of sex-specific DALY estimates due to cataract by year, age, and socioeconomic status at the global level. Paired Wilcoxon signed rank test, Pearson correlation, and linear regression analyses were performed to evaluate the socioeconomic-associated sex differences in cataract burden.

Results

Differences in rates of cataract by sex were similar between 1990 and 2015, with age-standardized DALY rates of 54.5 among men vs 65.0 among women in 1990 and 52.3 among men vs 67.0 among women in 2015. Women had higher rates than men of the same age, and sexual differences increased with age. Paired Wilcoxon signed rank test revealed that age-standardized DALY rates among women were higher than those among men for each HDI-based country group (z range, -4.236 to -6.093; P < .001). The difference (female minus male) in age-standardized DALY rates (r = -0.610 [P < .001]; standardized β = -0.610 [P < .001]) and the female to male age-standardized DALY rate ratios (r = -0.180 [P = .02]; standardized β = -0.180 [P = .02]) were inversely correlated with HDI.

Conclusions and Relevance

Although global cataract health care is progressing, sexual differences in cataract burden showed little improvement in the past few decades. Worldwide, women have a higher cataract burden than men. Older age and lower socioeconomic status are associated with greater differences in rates of cataract by sex. Our findings may enhance public awareness of sexual differences in global cataract burden and emphasize the importance of making sex-sensitive health policy to manage global vision loss caused by cataract.

Willingness to Pay for Cataract Surgeries Among Patients Visiting Eye Care Facilities in Dhaka, Bangladesh

BACKGROUND

Cataract is the leading cause of avoidable blindness globally. It is estimated that 89% of people with visual impairment live in low- and middle-income countries where the cost of cataract surgery represents a major barrier for accessing these services. Developing self-sustaining healthcare programs to cater the unmet demands warrants a better understanding of patients' willingness to pay (WTP) for their services.

OBJECTIVES

Using a sample of patients visiting eye care facilities in Dhaka, Bangladesh, we estimate WTP for two different cataract extraction techniques, namely small incision cataract surgery (SICS) and phacoemulsification.

METHODS

We used contingent valuation (CV) approach and elicited WTP through double-bounded dichotomous choice experiments. We interviewed 556 randomly selected patients (283 for SICS and 273 for phacoemulsification) from five different eye care hospitals of Dhaka. In this paper, we estimated the mean and marginal WTP using interval regression models. We also compared the estimated WTP and stated demand for cataract surgeries against the prevailing market prices of SICS and phacoemulsification.

RESULTS

We found the mean WTP of BDT 7579 (US$93) for SICS and BDT 10,208 (US$126) for phacoemulsification are equivalent to 12 and 16 days of household income, respectively. Household income and assets appeared as the major determinants of WTP for cataract surgeries. However, we did not find any significant association with gender, occupation, and household size among other socioeconomic characteristics. Comparisons between market prices and average WTP suggest it is possible to have a viable market for SICS, but a subsidy-based model for phacoemulsification will be financially challenging because of low WTP and high costs.

CONCLUSION

Our findings suggest lower-cost SICS can potentially provide patients access to surgeries to treat cataract conditions. Moreover, price discrimination and cross-subsidization could be a viable strategy to increase the service-uptake as well as ensure financial sustainability.

Prevalence of Pediatric Surgical Conditions Across Somaliland

IMPORTANCE

Although surgical conditions are increasingly recognized as causing a significant health care burden among adults in low- and middle-income countries (LMICs), the burden of surgical conditions among children in LMICs remains poorly defined.

OBJECTIVE

To estimate the prevalence of pediatric surgical conditions across Somaliland using a nationwide community-based household survey.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted through a national community-based sampling survey from August through December 2017 in Somaliland. Participants were 1503 children surveyed using the Surgeons OverSeas Assessment of Surgical Need (SOSAS).

MAIN OUTCOMES AND MEASURES

The SOSAS survey contains 2 components, including a section on household demographics, deaths, and financial information and sections querying children's history of surgical conditions.

RESULTS

In this cross-sectional study that included 1503 children (55.6% male; mean [SE] age, 6.4 [0.1] years), 221 surgical conditions were identified among 196 children, yielding a mean (SE) prevalence of pediatric surgical conditions of 12.2% (1.5%). Only 53 of these 221 surgical conditions (23.7%) had been surgically corrected at the time of the survey. The most common conditions encountered were congenital anomalies (33.8%) and wound-related injuries (24.6%). Nationally, an estimated 256 745 children have surgical conditions, with an estimated 88 345 to 199 639 children having unmet surgical needs.

CONCLUSIONS AND RELEVANCE

Using national sampling, this study found that children have a high burden of surgical conditions in Somaliland. These data highlight the need for a scale-up of pediatric surgical infrastructure and resources to provide the needed surgical care for children in LMICs.

Population need for primary eye care in Rwanda: A national survey

Background

Universal access to Primary Eye Care (PEC) is a key global initiative to reduce and prevent avoidable causes of visual impairment (VI). PEC can address minor eye conditions, simple forms of uncorrected refractive error (URE) and create a referral pathway for specialist eye care, thus offering a potential solution to a lack of eye health specialists in low-income countries. However, there is little information on the population need for PEC, including prevalence of URE in all ages in Sub-Saharan Africa.

Methods

A national survey was conducted of people aged 7 and over in Rwanda in September-December 2016. Participants were selected through two-stage probability proportional to size sampling and compact segment sampling. VI (visual acuity<6/12) was assessed using Portable Eye Examination Kit (PEEK); URE was detected using a pinhole and presbyopia using local near vision test. We also used validated questionnaires to collect socio-demographic and minor eye symptoms information. Prevalence estimates for VI, URE and need for PEC (URE, presbyopia with good distance vision, need for referrals and minor eye conditions) were age and sex standardized to the Rwandan population. Associations between age, sex, socio-economic status and the key outcomes were examined using logistic regression.

Results

4618 participants were examined and interviewed out of 5361 enumerated (86% response rate). The adjusted population prevalence of VI was 3.7% (95%CI = 3.0–4.5%), URE was 2.2% (95%CI = 1.7–2.8%) and overall need for PEC was 34.0% (95%CI = 31.8–36.4%). Women and older people were more likely to need PEC and require a referral.

Conclusions

Nearly a third of the population in Rwanda has the potential to benefit from PEC, with greater need identified in older people and women. Universal access to PEC can address unmet eye health needs and public health planning needs to ensure equitable access to older people and women.

International Vision Care: Issues and Approaches

Globally, 32.4 million individuals are blind and 191 million have moderate or severe visual impairment (MSVI); 80% of cases of blindness and MSVI are avoidable. However, great efforts are needed to tackle blindness and MSVI, as eye care in most places is delivered in isolation from and without significant integration with general health sectors. Success stories, including control of vitamin A deficiency, onchocerciasis, and trachoma, showed that global partnerships, multisectoral collaboration, public-private partnerships, corporate philanthropy, support from nongovernmental organizations-both local and international-and governments are responsible for the success of these programs. Hence, the World Health Organization's universal eye health global action plan for 2014-2019 has a goal of reducing the public health problem of blindness and ensuring access to comprehensive eye care; the plan aims to integrate eye health into health systems, thus providing universal eye health coverage (UEHC). This article discusses the challenges faced by low- and middle-income countries in strengthening the six building blocks of the health system. It discusses how the health systems in these countries need to be geared toward tackling the issues of emerging noncommunicable eye diseases, existing infectious diseases, and the common causes of blindness and visual impairment, such as cataract and refractive error. It also discusses how some of the comprehensive eye care models in the developing world have addressed these challenges. Moving ahead, if we are to achieve UEHC, we need to develop robust, sustainable, good-quality, comprehensive eye care programs throughout the world, focusing on the areas of greatest need. We also need to develop public health approaches for more complex problems such as diabetic retinopathy, glaucoma, childhood blindness, corneal blindness, and low vision. There is also a great need to train high-level human resources of all cadres in adequate numbers and quality. In addition to this, we need to exploit the benefits of modern technological innovations in information, communications, biomedical technology, and other domains to enhance quality of, access to, and equity in eye care.

Predictors of uptake of eye examination in people living with diabetes mellitus in three counties of Kenya

BACKGROUND

Diabetic retinopathy (DR) is a significant public health concern that is potentially blinding. Clinical practice guidelines recommend annual eye examination of patients with diabetes for early detection of DR. Our aim was to identify the demand-side factors that influence uptake of eye examination among patients already utilizing diabetes services in three counties of Kenya.

METHODS

We designed a clinic based cross-sectional study and used three-stage sampling to select three counties, nine diabetes clinics in these counties and 270 patients with diabetes attending these clinics. We interviewed the participants using a structured questionnaire. The two outcomes of interest were 'eye examination in the last 12 months' and 'eye examination ever'. The exposure variables were the characteristics of participants living with diabetes.

RESULTS

The participants had a mean age of 53.3 years (SD 14.1) and an average interval of 4 months between visits to the diabetes clinic. Only 25.6% of participants had ever had an eye examination in their lifetime, while 13.3% had it in the preceding year. The independent predictors of uptake were referral by diabetes services, patient knowledge of diabetes eye complications, comorbid hypertension and urban or semi-urban residence.

CONCLUSIONS

We conclude that access to retinal examination for DR is low in all three counties. An intervention that increases the knowledge of patients with diabetes about eye complications and promotes referral of patients with diabetes for eye examination may improve access to annual eye examination for DR.

Willingness to pay for cataract surgery is much lower than actual costs in Zamfara state, northern Nigeria

PURPOSE

Direct medical and non-medical costs incurred by those undergoing subsidised cataract surgery at Gusau eye clinic, Zamfara state, were recently determined. The aim of this study was to assess the willingness to pay for cataract surgery among adults with severe visual impairment or blindness from cataract in rural Zamfara and to compare this to actual costs.

METHODS

In three rural villages served by Gusau eye clinic, key informants helped identify 80 adults with bilateral severe visual impairment or blindness (<6/60), with cataract being the cause in at least one eye. The median amount participants were willing to pay for cataract surgery was determined. The proportion willing to pay actual costs of the (i) subsidised surgical fee (US$18.5), (ii) average non-medical expenses (US$25.2), and (iii) average total expenses (US$51.2) at Gusau eye clinic were calculated. Where participants would seek funds for surgery was determined.

RESULTS

Among 80 participants (38% women), most (n = 73, 91%) were willing to pay something, ranging from <US$1 to US$186 (median US$18.5, interquartile range 6.2-31.1). Approximately half of the participants (n = 41) were willing to pay US$18.5 (78% men), one-third (n = 26) were willing to pay US$25.2 (77% men); and 11% (n = 9) were willing to pay US$51.2 (all men). Only six participants (8%) already had the money to pay; one quarter (n = 20) would need to sell possessions to raise the funds.

CONCLUSION

Willingness to pay for cataract surgery among adults with operable cataract in rural Zamfara state is far lower than current costs of undergoing surgery. People who were widowed-most of whom were women-were willing to pay least. Further financial support is required for cataract surgery to be universally accessible.

Involvement of Nrf2 in Ocular Diseases

The human body harbors within it an intricate and delicate balance between oxidants and antioxidants. Any disruption in this checks-and-balances system can lead to harmful consequences in various organs and tissues, such as the eye. This review focuses on the effects of oxidative stress and the role of a particular antioxidant system—the Keap1-Nrf2-ARE pathway—on ocular diseases, specifically age-related macular degeneration, cataracts, diabetic retinopathy, and glaucoma. Together, they are the major causes of blindness in the world.