Factors associated with late presentation of cataract in rural and urban patients: A cross-sectional study in Maharashtra

Introduction

According to the World Health Organization, cataract is the most important cause of blindness in the world. Cataract-induced blindness accounts for 47.8% of blindness, which is about 17.7 million blind people.^[1] Ideally, the aim is to operate sufficient cataracts every year so that each patient with operable cataract (visual loss justifying surgery) can be benefited.^[2] With increasing life expectancy, the elderly population is on the rise and so is the prevalence of cataract.

In India and in many other developing parts of the world, the burden of cases presenting with advanced cataract is high.^[2], ^[3], ^[4], ^[5], ^[6] Studies talking about delayed presentation of cataract have majorly focused on lens-induced glaucoma. The reasons for delay in presentation have been explored by a few researchers in the past. Lack of family support, lack of awareness, poor financial support, acceptance of poor vision as a part of ageing, fear of surgery and associated systemic illnesses have been cited as some of the reasons.^[3], ^[4], ^[7] There is scarcity of local data about the proportion of late presenters of cataract and the factors associated with it. Also, to the best of our knowledge, there is no study which explores both, the rural and urban scenarios regarding this issue. Hence we collected data from rural and urban patients attending a rural hospital to determine the proportion of late cataract presenters and associated factors. We believe that the results of this study will help us understand the local issues and guide us in designing implementation strategies to encourage “early” presentation in cataract patients.

Material and Methods

The study was carried out over a period of three months from October 2019 to December 2019 in a rural hospital in north-west Maharashtra. Approval was obtained from the Institutional Ethics Committee. Adult patients visiting the ophthalmology out-patient department (OPD) of the hospital with best corrected visual acuity less than 6/60 in the cataractous eye were diagnosed as “late presenters of cataract” and were included in the study. Informed consent was sought from every patient after explaining the study details carefully. In all, 3475 patients visited the OPD during the study period. Out of these, 1248 (36%) patients were diagnosed with cataract. There were 430 (34.4%) “late presenters” of which 422 patients provided consent for participation and were included in the study. Socio-demographic details such as age, sex, address, education, occupation, monthly family income and marital status were recorded. A detailed history taking and examination was conducted as per the standard clinical protocol. The patients were asked to describe their reasons for “delayed” presentation with the help of a structured questionnaire. The data was entered in a data collection form by research assistants and entered into SPSS version 23 for analysis. The data is presented as frequencies and means (± SD) as applicable. The chi-square test is used for determining associations between categorical variables and Student t-test has been used to determine differences between means as applicable.

Results

Data was collected from 422 patients. There was an almost equal distribution of males and females in our study sample with 212 (50.2%) male and 210 (49.8%) female patients. The mean age of patients was 60.9 years ± 9.5 years (minimum 36 years and maximum 85 years). Majority of the patients (286/422, 67.8%) came from rural areas. [Table 1] gives details of sociodemographic characteristics of our study sample.

There was no statistically significant difference between the ages of male and female patients in our study sample (61.1 years Vs. 60.6 years respectively, p=0.569). It was observed that 130/422 (30.8%) patients had some systemic comorbidity. A majority of the patients were hypertensive (42, 32.3%) followed by a combination of diabetes mellitus and hypertension in 38 (29.2%) patients and diabetes mellitus alone in 34 (26.1%) patients. Other comorbidities that were found were chronic obstructive pulmonary disease (12, 9.2%) and ischemic heart disease (4, 3%). The majority of the rural patients were females (158/286, 55.2%) as compared to only 52/136 (38.2%) female patients from urban areas. This difference was statistically significant (p=0.001). The mean distance travelled by the patients to reach our hospital was 53 km (minimum 2 and maximum 200 km). Using the independent T-test, it was seen that the mean distance travelled to reach the hospital by urban dwellers was significantly greater than that travelled by rural residents (102.7 km Vs. 29.3 km, p<0.000). When examined with respect to sex of the patient, it was found that male patients travelled a significantly greater distance as compared to female patients (57.95 km Vs. 47.97 km respectively, p=0.014).

When asked to describe the reasons for delayed presentation of cataract, a variety of responses were obtained as summarized in [Table 2]. The most common reason that patients attributed their delayed presentation to, was their lack of awareness (110/422, 26.1%). The second and third most common reasons were poor financial condition (84/422, 19.9%) and lack of family support (54/422, 12.8%) respectively.

As shown in [Table 3], using the chi-square test to look for associations between sex of the patient and reasons for delayed presentation, it was found that although not statistically significant, a greater proportion of females as compared to males accepted diminished vision as part of ageing and relied on good vision in the contralateral eye (40/210 (19%) Vs. 34/212 (16%) respectively, p=0.154). We found similar results when “lack of awareness” as a reason was studied. More female patients (60/210, 28.6%) gave this reason as compared to males (50/212, 23.6%) p=0.154 (not significant). As for poverty and concern about their daily wages was concerned, male patients outnumbered females (76/212 (35.8%) Vs. 54/210 (25.7%) respectively, p=0.154). When reasons for delayed presentation were compared between the rural and urban patients, it was found that significantly greater proportion of patients from the rural areas lacked awareness, were concerned about losing their daily wages and gave poverty as the reason and finally, pulled on with good vision in the contralateral eye or had accepted the diminished vision as an integral part of ageing ([Table 4]).

Discussion

The patients attending our OPD were from rural as well as urban areas, but being located in a rural area, the number of patients coming from the adjacent urban areas was comparatively lesser than that of the rural patients. The factors associated the large proportion of late presenters found in our study were mainly financial, social and personal. Factors such as lack transport facility, inability to forego daily wages and acceptance of poor vision as a part of the ageing process were found contributory to the delayed presentation.

In this study, a huge majority of our participants were either illiterate or educated only upto 10^th standard. This could have contributed to the large proportion of patients who lacked awareness (26%) and hence ended up presenting late with cataract. In an earlier study carried out in urban Maharashtra,^[8] lack of awareness was found in 16% patients and in another study conducted in rural Andhra Pradesh,^[9] it was found to be 4%. A higher prevalence of lack of awareness (48%) has been reported from a study from Nepal^[10] while that from Ghaziabad (29%) is comparable to our study.^[11] Poor financial condition was found to be the second most common factor associated with delayed presentation in our study. However, the cataract surgery is carried out free of charge at our hospital. It appears that there could have been a lack of awareness about this, as well. In addition, it could have been difficult for these patients to bear the ancillary expenses for transport of self and accompanying persons, food and medicines. Also, for many, a visit to the hospital meant forgoing their daily wages, a reason which was cited by 10.9% patients. In this respect, more males than females were seen to be concerned. Also, this reason was more prevalent in rural patients as compared to urban patients. In a similar study carried out in Nigeria,^[12] financial reasons contributed to 61%, while a study in Karnataka found the same in 13.4% patients.^[13] Lack of family support was expressed as another important reason by patients (12.8%) in this study.

The long distances needed to be travelled to reach the hospital have contributed to the delayed presentation of cataract in our study. It was seen that the mean distance travelled by patients to reach our hospital was 53 km. The distance travelled by urban patients was greater than that travelled by the rural patients. This was due to the rural location of our hospital. In a study carried out in an urban area, the mean distance travelled was found to be 25 km.^[8] A small proportion of our patients (7%) cited difficulty in reaching the hospital as a reason which was comparable to the 5% found in a similar Indian study.^[11] Good vision in the other eye or acceptance of poor vision as part of ageing was reported by 17.6% of patients as a reason for presenting late. Again, this can be attributed to the highly prevalent illiteracy in our study sample. One of the reasons could be that patients were simply unaware that loss of vision can be treated and good vision restored. Apart from illiteracy, since both these reasons were found more prevalent among female patients, this could reflect the submissive nature of women in the rural areas. Female patients lacked the motivation to go to the hospital so far as they could carry out household and routine chores. In a similar study carried out in Karnataka,^[9] it was found to be a reason for delayed presentation in 21.5% patients.

There was a small proportion of patients (2.4%) in whom fear of surgery was found to be the reason for delayed presentation. We believe that this can be dealt with by counselling by doctors and relatives of patients who have undergone cataract surgery with good visual outcome. Fear of surgery has been reported at 21.9% in a study from rural India.^[14]

The lack of awareness can be overcome by imparting knowledge by healthcare workers in the villages with special focus on counseling women. Those who have undergone successful cataract surgery can be motivators in this process.

Conclusion

A multipronged approach in order to facilitate personal and social awareness and accessibility would be needed to overcome the various hurdles in the way of timely presentation of cataract.

Source of Funding

None.

Conflict of Interest

None.