The long term impact of cataract surgery on quality of life, activities and poverty: results from a six year longitudinal study in Bangladesh and the Philippines.

BACKGROUND: Cataract surgery has been shown to improve quality of life and household economy in the short term. However, it is unclear whether these benefits are sustained over time. This study aims to assess the six year impact of cataract surgery on health related quality of life (HRQoL), daily activities and economic poverty in Bangladesh and The Philippines. METHODS AND FINDINGS: This was a longitudinal study. At baseline people aged ≥50 years with visual impairment due to cataract ('cases') and age-, sex-matched controls without visual impairment were interviewed about vision specific and generic HRQoL, daily activities and economic indicators (household per capita expenditure, assets and self-rated wealth). Cases were offered free or subsidised cataract surgery. Cases and controls were re-interviewed approximately one and six years later. At baseline across the two countries there were 455 cases and 443 controls. Fifty percent of cases attended for surgery. Response rates at six years were 47% for operated cases and 53% for controls. At baseline cases had poorer health and vision related QoL, were less likely to undertake productive activities, more likely to receive assistance with activities and were poorer compared to controls (p<0.05). One year after surgery there were significant increases in HRQoL, participation and time spent in productive activities and per capita expenditure and reduction in assistance with activities so that the operated cases were similar to controls. These increases were still evident after six years with the exception that time spent on productive activities decreased among both cases and controls. CONCLUSION: Cataract causing visual loss is associated with reduced HRQoL and economic poverty among older adults in low-income countries. Cataract surgery improves the HRQoL of the individual and economy of the household. The findings of this study suggest these benefits are sustained in the long term.

Predictors of attendance and barriers to cataract surgery in Kenya, Bangladesh and the Philippines.

PURPOSE: Cataract is the leading cause of blindness worldwide, and is particularly common in low- and middle-income countries. Our study aims to identify the predictors for and barriers to acceptance of cataract surgery in Kenya, Bangladesh and the Philippines. METHODS: Cases were individuals aged ≥50 years and with best corrected VA of <6/24 in the better eye due to cataract who were identified through population-based surveys and community-based case detection. Cases were asked why they had not attended for surgery. They were offered free cataract surgery and followed-up at one year. Non-acceptors were interviewed to identify barriers to accepting surgery. RESULTS: Of all participants, 58.6% attended for cataract surgery in Kenya, 53.9% Bangladesh and 47.1% the Philippines. Younger age was a predictor for attendance for surgery in all three countries. In Bangladesh and Kenya, male gender and psychosocial score were predictors. At baseline "cost" and "unaware of cataract" were most frequently reported barriers to uptake of surgery in the three settings. At follow-up, "surgical services inaccessible" was one of the two most frequently reported barriers in Kenya and the Philippines while "fear" was most frequently reported in Bangladesh and the Philippines. There were no consistent predictors of the most frequently reported barriers across the different settings. CONCLUSIONS: Future services need to focus on increasing uptake among older people and women. Cost is often reported as a barrier but this may conceal more complicated underlying barriers which need to be explored through in-depth qualitative research. IMPLICATIONS FOR REHABILITATION: Cataract is the leading cause of blindness worldwide, and is particularly common in low- and middle-income countries. Evidence suggests that even when surgical services are available, there can be a lack of demand and low utilization resulting from barriers to uptake. Older cataract patients, females and especially older females are least likely to attend for surgery. Future cataract surgical programmes should put special emphasis on targeting and increasing uptake in these groups.

Does cataract surgery alleviate poverty? Evidence from a multi-centre intervention study conducted in Kenya, the Philippines and Bangladesh.

BACKGROUND: Poverty and blindness are believed to be intimately linked, but empirical data supporting this purported relationship are sparse. The objective of this study is to assess whether there is a reduction in poverty after cataract surgery among visually impaired cases. METHODOLOGY/PRINCIPAL FINDINGS: A multi-centre intervention study was conducted in three countries (Kenya, Philippines, Bangladesh). Poverty data (household per capita expenditure--PCE, asset ownership and self-rated wealth) were collected from cases aged ≥50 years who were visually impaired due to cataract (visual acuity<6/24 in the better eye) and age-sex matched controls with normal vision. Cases were offered free/subsidised cataract surgery. Approximately one year later participants were re-interviewed about poverty. 466 cases and 436 controls were examined at both baseline and follow-up (Follow up rate: 78% for cases, 81% for controls), of which 263 cases had undergone cataract surgery ("operated cases"). At baseline, operated cases were poorer compared to controls in terms of PCE (Kenya: $22 versus £35 p = 0.02, Bangladesh: $16 vs $24 p = 0.004, Philippines: $24 vs 32 p = 0.0007), assets and self-rated wealth. By follow-up PCE had increased significantly among operated cases in each of the three settings to the level of controls (Kenya: $30 versus £36 p = 0.49, Bangladesh: $23 vs $23 p = 0.20, Philippines: $45 vs $36 p = 0.68). There were smaller increases in self-rated wealth and no changes in assets. Changes in PCE were apparent in different socio-demographic and ocular groups. The largest PCE increases were apparent among the cases that were poorest at baseline. CONCLUSIONS/SIGNIFICANCE: This study showed that cataract surgery can contribute to poverty alleviation, particularly among the most vulnerable members of society. This study highlights the need for increased provision of cataract surgery to poor people and shows that a focus on blindness may help to alleviate poverty and achieve the Millennium Development Goals.

Visual impairment from cataract and health related quality of life: results from a case-control study in the Philippines.

PURPOSE: To evaluate a vision related quality of life (VRQoL) scale, the World Health Organization Prevention of Blindness and Deafness Visual Function-20 (WHO/ PBD VF20) and describe the relationship between visual impairment from cataract and vision related and generic Health Related Quality of Life (HRQoL) in a case-control study of adults aged > or = 50 years in the Philippines. METHODS: Two hundred and thirty eight population based persons visually impaired from cataract and 163 age- gender- matched controls with normal vision were interviewed using the WHO/PBD VF20 and European Quality of Life (EuroQol) questionnaire (an HRQoL). The WHO/PBD VF20 was evaluated using standard psychometric tests. RESULTS: The WHO/PBD VF20 had good item acceptability and validity. Cases had significantly poorer VRQoL than controls and worsening Visual Acuity (VA) was associated with worsening VRQoL. The general functioning subscale had good internal consistency. The psychosocial sub-scale had a Cronbach's alpha of 0.61, just below the generally accepted criteria of 0.70. Cases were much more likely than controls to report problems with the Euroqol five descriptive domains (EQ-5D)and had significantly poorer self-rated health. CONCLUSIONS: The study supports the use of the WHO/PBD VF20 in a Philippine population and highlights the worsening VRQoL associated with cataract vision loss. The poorer generic HRQoL among cases compared to controls indicates an impact of visual impairment on perceived health and well-being, beyond vision-specific experience.

A case-control study to assess the relationship between poverty and visual impairment from cataract in Kenya, the Philippines, and Bangladesh.

BACKGROUND: The link between poverty and health is central to the Millennium Development Goals (MDGs). Poverty can be both a cause and consequence of poor health, but there are few epidemiological studies exploring this complex relationship. The aim of this study was to examine the association between visual impairment from cataract and poverty in adults in Kenya, Bangladesh, and the Philippines. METHODS AND FINDINGS: A population-based case-control study was conducted in three countries during 2005-2006. Cases were persons aged 50 y or older and visually impaired due to cataract (visual acuity < 6/24 in the better eye). Controls were persons age- and sex-matched to the case participants with normal vision selected from the same cluster. Household expenditure was assessed through the collection of detailed consumption data, and asset ownership and self-rated wealth were also measured. In total, 596 cases and 535 controls were included in these analyses (Kenya 142 cases, 75 controls; Bangladesh 216 cases, 279 controls; Philippines 238 cases, 180 controls). Case participants were more likely to be in the lowest quartile of per capita expenditure (PCE) compared to controls in Kenya (odds ratio = 2.3, 95% confidence interval 0.9-5.5), Bangladesh (1.9, 1.1-3.2), and the Philippines (3.1, 1.7-5.7), and there was significant dose-response relationship across quartiles of PCE. These associations persisted after adjustment for self-rated health and social support indicators. A similar pattern was observed for the relationship between cataract visual impairment with asset ownership and self-rated wealth. There was no consistent pattern of association between PCE and level of visual impairment due to cataract, sex, or age among the three countries. CONCLUSIONS: Our data show that people with visual impairment due to cataract were poorer than those with normal sight in all three low-income countries studied. The MDGs are committed to the eradication of extreme poverty and provision of health care to poor people, and this study highlights the need for increased provision of cataract surgery to poor people, as they are particularly vulnerable to visual impairment from cataract.

The impact of cataract on time-use: results from a population based case-control study in Kenya, the Philippines and Bangladesh.

PURPOSE: Cataract is the leading cause of blindness in the world, and is particularly common in low-income countries. Cataract is asserted to increase poverty through reduced productivity; however there is a lack of empirical data supporting this claim. The aim of this study was to examine the relationship between visual impairment from cataract with time-use in adults (aged >or= 50 years) in Kenya, Bangladesh, and The Philippines. METHODS: A population-based case-control study was conducted in three countries. Detailed time-use data were collected through interview from 139, 216 and 238 cases with visually impairing cataract and 124, 280 and 163 controls with normal vision in Kenya, Bangladesh and Philippines, respectively during 2005-2006. RESULTS: Cases were substantially less likely than controls to participate in productive activities, including paid work and non-market activities (odds ratio [OR] across three countries is 0.2 95% confidence interval (CI): 0.1-0.3) and in leisure outside of the household (OR 0.7, 95% CI: 0.5, 0.9). Among cases, those with more severe visual impairment spent significantly less time on productive activities and leisure outside of the home, and more time on "no particular activity" (Kenya and Bangladesh) or leisure in the home (The Philippines). Cases were substantially more likely to require assistance in any activity than controls in Kenya (OR 9.8, 95% CI: 3.3, 29.8), Bangladesh (OR 8.6, 95% CI: 5.1-14.4) and the Philippines (OR 2.7, 95% CI: 1.4-5.1). CONCLUSIONS: Cataract visual impairment restricts engagement in productive and leisure activities in this population of older adults in three different low income settings.

Rapid assessment of avoidable blindness in Negros Island and Antique District, Philippines.

OBJECTIVES: To conduct rapid assessments of avoidable blindness to estimate the magnitude and causes of blindness in people aged >/=50 years in Negros Island and Antique district, Philippines. METHODS: Clusters of 50 people aged >/=50 years were sampled with probability proportionate to size. Households within clusters were selected through compact segment sampling. Visual acuity (VA) was measured with a tumbling "E" chart. Ophthalmologists examined people with VA<6/18 in either eye. RESULTS: In Negros, 2774 of 3649 enumerated subjects were examined (76.0%) and 3177 of 3842 enumerated subjects in Antique (82.7%). The prevalence of blindness (presenting VA<3/60 in better eye) was 2.6% (95% CI = 2.0 to 3.2%) in Negros and 3.0% (2.4 to 3.6%) in Antique. The leading cause of blindness was untreated cataract, and was refractive error for visual impairment (VA<6/18 to >/=6/60). Most of the cases of blindness (67% in Negros, 82% in Antique) and visual impairment (94% in Negros, 95% in Antique) were avoidable (ie, operated and unoperated cataract, refractive error and corneal scar). In Negros, 23% of eyes had a poor outcome after cataract surgery, and 13% in Antique. CONCLUSIONS: The prevalence of blindness in two areas in the Philippines was relatively low. Since most cases were avoidable, further reductions are possible.