Gendered Disparities in Quality of Cataract Surgery in a Marginalised Population in Pakistan: The Karachi Marine Fishing Communities Eye and General Health Survey.

BACKGROUND: Marine fishing communities are among the most marginalised and hard-to-reach groups and have been largely neglected in health research. We examined the quality of cataract surgery and its determinants, with an emphasis on gender, in marine fishing communities in Karachi, Pakistan, using multiple indicators of performance. METHODS AND FINDINGS: The Karachi Marine Fishing Communities Eye and General Health Survey was a door-to-door, cross-sectional study conducted between March 2009 and April 2010 in fishing communities living on 7 islands and in coastal areas in Keamari, Karachi, located on the Arabian Sea. A population-based sample of 638 adults, aged ≥ 50 years, was studied. A total of 145 eyes (of 97 persons) had undergone cataract surgery in this sample. Cataract surgical outcomes assessed included vision (presenting and best-corrected with a reduced logMAR chart), satisfaction with surgery, astigmatism, and pupil shape. Overall, 65.5% of the operated eyes had some form of visual loss (presenting visual acuity [PVA] < 6/12). 55.2%, 29.0%, and 15.9% of these had good, borderline, and poor visual outcomes based on presenting vision; with best correction, these values were: 68.3 %, 18.6%, and 13.1%, respectively. Of 7 covariates evaluated in the multivariable generalized estimating equations (GEE) analyses, gender was the only significant independent predictor of visual outcome. Women's eyes were nearly 4.38 times more likely to have suboptimal visual outcome (PVA<6/18) compared with men's eyes (adjusted odds ratio 4.38, 95% CI 1.96-9.79; P<0.001) after adjusting for the effect of household financial status. A higher proportion of women's than men's eyes had an irregular pupil (26.5% vs. 14.8%) or severe/very severe astigmatism (27.5% vs. 18.2%). However, these differences did not reach statistical significance. Overall, more than one fourth (44/144) of cataract surgeries resulted in dissatisfaction. The only significant predictor of satisfaction was visual outcome (P <0.001). CONCLUSIONS: The quality of cataract surgery in this marginalised population, especially among women, falls well below the WHO recommended standards. Gender disparities, in particular, deserve proactive attention in policy, service delivery, research and evaluation.

Eye Care Service Use and Its Determinants in Marginalized Communities in Pakistan: The Karachi Marine Fishing Communities Eye and General Health Survey.

PURPOSE: To examine gender, ethnic, and socioeconomic differences in access to eye care services in marine fishing communities in Karachi, Pakistan. METHODS: The Karachi Marine Fishing Communities Eye and General Health Survey was a door-to-door, cross-sectional survey conducted between March 2009 and April 2010 in fishing communities in Keamari, Karachi, located on the coast of the Arabian Sea. Adults aged ≥50 years living on three islands and in four coastal areas were enrolled. Participants underwent a detailed interview regarding sociodemographics, eye problems and eye care service use, testing of presenting and best-corrected visual acuity with a reduced logMAR chart, and detailed eye examination. RESULTS: A total of 700 people were planned to be included in the study; 638 (91.1%) were interviewed and examined. Most participants were extremely poor and had no formal education. Only 45.3% (95% confidence interval, CI, 41.4-49.2%) of participants reported having had an eye examination in the past; 12.1% (95% CI 9.5-14.6%) and 30.9% (95% CI 27.3-34.5%) had seen an eye doctor within the last year or prior 5 years, respectively. In the multivariable analysis, ethnicity was the strongest independent predictor of eye care service use, followed by self-reported eye problems and diabetes. Ethnic Bengalis were 4.2 times less likely (adjusted odds ratio 0.24, 95% CI 0.15-0.38; p < 0.001) to have had an eye examination in the past than Kutchis. CONCLUSIONS: Despite a high prevalence of visual impairment and blindness, levels of eye care examinations in fishing communities, especially among ethnic Bengalis, are disappointingly low. Such communities deserve particular attention in Vision 2020 and other national and international strategies and plans.

Self-perceived barriers to eye care in a hard-to-reach population: the Karachi Marine Fishing Communities Eye and General Health Survey.

PURPOSE: We examined self-reported barriers to eye care among marginalized, hard-to-reach fishing communities in Karachi, Pakistan. METHODS: The Karachi Marine Fishing Communities Eye and General Health Survey was a cross-sectional survey conducted between March 2009 and April 2010 in fishing communities in Keamari, Karachi, located on the coast of the Arabian Sea. Adults aged ≥50 years living on seven islands and coastal areas were interviewed regarding sociodemographic background, experience of eye problems, eye care use, and barriers to access. They also were examined to determine visual acuity with a reduced logMAR chart and underwent a detailed eye examination. RESULTS: Of 700 people planned to be included in the study, 638 (91.1%) were interviewed and examined. Of these participants, 599 (93.9%) lived in extreme poverty and 84.3% had no school-based education, and 349 (54.7%; 95% confidence interval [CI], 50.8-58.6) of them had never had an eye examination. The common barriers to access identified included a perceived lack of or low need (176/349 or 50.4%), financial hardships (36.4%), "fears" (8.6%), and social support constraints (6.3%). Of those reporting a "lack of need," 21.9% had significant visual loss. Financial hardships, "fears," and social support constraints were more prevalent among women than men. Bengalis compared to Kutchis and Sindhis, and individuals with "poor/fragile" household financial status (self-reported) compared to those with "fine" status, were more likely to cite financial hardships. CONCLUSIONS: Access to eye care in this marginalized population is substantially hindered by perceived lack of need, financial hardships, and a range of "fears" and anxieties, despite a large unmet need. These barriers should be addressed while paying particular attention to gender, and ethnic and socioeconomic differences.