Understanding barriers to cataract surgery among older persons in rural China through focus groups.

PURPOSE: To utilize focus groups (FGs) to identify barriers to cataract surgery specific to older persons in rural Guangdong, China. METHODS: Three focus groups in separate locations were carried out for persons aged 60 years and above with best-corrected vision <= 6/18 due to cataract, either accepting or refusing surgery. Participants also ranked responses to questions about acceptance of surgery among the elderly. FG transcripts were coded independently by two investigators using qualitative data management software. RESULTS: Twenty participants had a mean age of 72.7 ± 6.1 years, 14 (70.0%) were women and 17 (85.0%) were blind (best-corrected vision <= 6/60) in at least one eye. Cost was ranked by two of three groups as the main barrier to surgery, and all groups listed reducing cost as the best strategy to increase surgical uptake. Many respondents planned to use China's New Cooperative Medical Scheme (NCMS) health insurance to pay for surgery. Participants showed poor understanding of cataract, but ranked educational interventions low as methods of increasing uptake. Though opinions of local service quality were poor, respondents did not see quality as an important barrier to accepting service. Participants frequently depended on family members to pay for surgery. CONCLUSIONS: Contrary to some previous reports, cost may be an important barrier to cataract surgery in rural China, which NCMS may help to alleviate. Educational interventions to increase knowledge about cataract are needed, but may face skepticism among patients. Strategies to promote cataract surgery should target the entire family.

Willingness to pay for potential enhancements to a low-cost cataract surgical package in rural southern China.

PURPOSE: To assess determinants of patients' willingness to pay (WTP) for potential components of a multi-tiered cataract surgical package offered by a non-governmental organization (NGO) in rural China. DESIGN: Cross-sectional study. METHODS: Demographic and clinical data were collected from 505 patients presenting for cataract screening or surgery in Yangjiang, China. Willingness to pay for potential enhancements to the current surgery package was assessed using a bidding format with random payment cards. RESULTS: Among 426 subjects (84.4%) completing interviews, the mean age was 73.9 ± 7.3 years, 67.6% were women and 73% (n = 310) would pay for at least one offering, with 33-38% WTP for each item. Among those who would pay, the mean WTP for food was US$1.68 ± 0.13, transportation US$3.24 ± 0.25, senior surgeon US$50.0 ± 3.36 and US$89.4 ± 4.19 for an imported intra-ocular lens (IOL). The estimated total recovery from these enhancements under various assumptions would be US$20-50 (compared to the current programme price of US$65). In multivariate models, WTP for the senior surgeon increased with knowledge of a person previously operated for cataract (OR = 2.13, 95% CI 1.42-3.18, p < 0.001). Willingness to pay for the imported IOL increased with knowledge of a previously operated person (OR = 1.85, 95% CI 1.24-2.75, p < 0.01) and decreased with age >75 years (OR = 0.61, 0.40-0.93, p < 0.05). CONCLUSIONS: Opportunities exist to increase cataract programme revenues through multi-tiered offerings in this setting, allowing greater subsidization of low-income patients. Personal familiarity with cataract surgery is important in determining WTP. © 2011 The Authors. Acta Ophthalmologica © 2011 Acta Ophthalmologica Scandinavica Foundation.

Self correction of refractive error among young people in rural China: results of cross sectional investigation.

OBJECTIVE: To compare outcomes between adjustable spectacles and conventional methods for refraction in young people. DESIGN: Cross sectional study. SETTING: Rural southern China. PARTICIPANTS: 648 young people aged 12-18 (mean 14.9 (SD 0.98)), with uncorrected visual acuity ≤ 6/12 in either eye. INTERVENTIONS: All participants underwent self refraction without cycloplegia (paralysis of near focusing ability with topical eye drops), automated refraction without cycloplegia, and subjective refraction by an ophthalmologist with cycloplegia. MAIN OUTCOME MEASURES: Uncorrected and corrected vision, improvement of vision (lines on a chart), and refractive error. RESULTS: Among the participants, 59% (384) were girls, 44% (288) wore spectacles, and 61% (393/648) had 2.00 dioptres or more of myopia in the right eye. All completed self refraction. The proportion with visual acuity ≥ 6/7.5 in the better eye was 5.2% (95% confidence interval 3.6% to 6.9%) for uncorrected vision, 30.2% (25.7% to 34.8%) for currently worn spectacles, 96.9% (95.5% to 98.3%) for self refraction, 98.4% (97.4% to 99.5%) for automated refraction, and 99.1% (98.3% to 99.9%) for subjective refraction (P = 0.033 for self refraction v automated refraction, P = 0.001 for self refraction v subjective refraction). Improvements over uncorrected vision in the better eye with self refraction and subjective refraction were within one line on the eye chart in 98% of participants. In logistic regression models, failure to achieve maximum recorded visual acuity of 6/7.5 in right eyes with self refraction was associated with greater absolute value of myopia/hyperopia (P<0.001), greater astigmatism (P = 0.001), and not having previously worn spectacles (P = 0.002), but not age or sex. Significant inaccuracies in power (≥ 1.00 dioptre) were less common in right eyes with self refraction than with automated refraction (5% v 11%, P<0.001). CONCLUSIONS: Though visual acuity was slightly worse with self refraction than automated or subjective refraction, acuity was excellent in nearly all these young people with inadequately corrected refractive error at baseline. Inaccurate power was less common with self refraction than automated refraction. Self refraction could decrease the requirement for scarce trained personnel, expensive devices, and cycloplegia in children's vision programmes in rural China.

Early assessment of visual acuity after cataract surgery in rural Indonesia.

BACKGROUND: The accuracy and impact on service uptake of early examination after cataract surgery is not known. DESIGN:   Prospective cohort study. PARTICIPANTS: Cataract patients in rural Indonesia. METHODS: Visual acuity was measured preoperatively, 1day, 1-3, 4-6 and >12weeks after surgery, and 6-8months postoperatively at an outreach examination. Acceptance of second-eye surgery and spectacles was evaluated. MAIN OUTCOME MEASURE: Presenting visual acuity in the operated eye. RESULTS: Among 241 subjects (extracapsular surgery 84%), examinations at 1day, 1-3, 4-6 and >12weeks and 6-8months were completed for 100% (241), 90.9% (219), 67.6% (163), 22.0% (53) and 80.0% (193), respectively. Among subjects at the final examination (mean age 65.8±10.6years, 51.8% male), 73.6% had bilateral preoperative presenting visual acuity≤6/60. By 4-6weeks, the proportion with good (≥6/18) or poor (≤6/60) visual acuity did not differ significantly from the final examination. Among 49 persons accepting free second-eye surgery, 69.4% (34) and 16.3% (8) returned to clinic at 4-6 and >12weeks, respectively. Among 131 patients (67.9%) paying US$7 for glasses, 94 (71.8%) and 30 (22.9%) attended 4- to 6- and >12-week examinations, respectively. CONCLUSION: Even with large-incision surgery, early assessment of postoperative vision is representative of final vision, and may help deliver postoperative services to more of those needing them. © 2011 The Authors. Clinical and Experimental Ophthalmology © 2011 Royal Australian and New Zealand College of Ophthalmologists.

Ophthalmology. 2011 Dec;118(12):2343-50. doi: 10.1016/j.ophtha.2011.06.016. Epub 2011 Sep 1. Randomized, controlled trial of an educational intervention to promote spectacle use in rural China: the see well to learn well study.

OBJECTIVE: To test an educational intervention promoting the purchase of spectacles among Chinese children. DESIGN: Randomized, controlled trial. PARTICIPANTS: Children in years 1 and 2 of all 20 junior and senior high schools (ages 12-17 years) in 3 rural townships in Guangdong, China. METHODS: Children underwent visual acuity (VA) testing, and parents of participants with presenting VA worse than 6/12 in either eye improving by more than 2 lines with cycloplegic refraction were recommended to purchase glasses. Children at 10 randomly selected schools received a lecture, video, and classroom demonstration promoting spectacle purchase. MAIN OUTCOME MEASURES: Self-reported purchase of spectacles (primary outcome) and observed wear or possession of newly purchased glasses (secondary outcome) at follow-up examinations (mean, 219 ± 87 days after the baseline visit). RESULTS: Among 15 404 eligible children, examinations were completed for 6379 (74.6%) at intervention schools and 5044 (73.6%) at control schools. Spectacles were recommended for 2236 (35.1%) children at intervention schools and for 2212 (43.9%) at control schools. Of these, 417 (25.7%) intervention schools children and 537 (34.0%, P = 0.45) control schools children reported buying glasses. Predictors of purchase in regression models included female gender (P = 0.02), worse uncorrected VA (P < 0.001), and higher absolute value of refractive error (P = 0.001). Neither the rate of self-reported purchase of glasses or observed wear or possession of newly purchased glasses differed between control schools and intervention schools in mixed-effect logistic regression models. Among children not purchasing glasses, 21.7% had better-eye VA of worse than 6/18. CONCLUSIONS: An intervention based on extensive pilot testing and focus groups in the area failed to promote spectacle purchase or wear. The high burden of remaining uncorrected poor vision underscores the need to develop better interventions. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Prevention of Cataract Blindness in Rural China.

China has undergone dramatic economic and social reforms during last 30 years, leading to a notably higher level of living standards and health care access for Chinese citizens. However, China's cataract surgical rate of 780 cases/y per million population trails Asian neighbors with lower income levels such as India and Vietnam. Eye care providers and patients encounter many barriers in gaining access to one another.Hands-on training programs conducted by international nongovernmental organizations and the government have helped to increase the number of qualified cataract surgeons in rural area, but establishing a residency training system that produces ophthalmologists capable of performing independent surgery is the only sustainable way to meet the increasing demand for surgery from an aging population. The New Rural Cooperative Medical System has successfully reduced the financial burden of cataract surgery for the rural population; however, reimbursement for outpatient treatment of leading eye diseases is needed.Community outreach screening combined with education is essential in rural areas' increased demand for surgery. Methods to optimize the yield from such screening must still be devised and proven, however. Improvements in the hospital administration and management structure are also needed to improve the efficiency of China's rural hospitals in delivering high-quality, low-cost cataract surgical services.

Compliance with follow-up after cataract surgery in rural China.

PURPOSE:

To evaluate reasons for non-compliance with post-cataract surgical follow-up in rural China, and assess the impact of incentives on improving compliance.

METHODS:

Patients having undergone cataract surgery more than 3 months previously at cataract surgery training hospitals in Guangdong were invited by telephone and advertisements to a hospital-based study examination, with compensation for travel costs (US$7). Information on prior post-surgical follow up was collected by questionnaire at the hospital or by telephone. Logistic regression was used to assess predictors of post-operative attendance with or without compensation.

RESULTS:

Among 518 eligible patients, 426 (82.2%) underwent interviews and 342 (66.0%) attended the compensated study examination. Ninety nine participants (23.2%) reported previously returning for uncompensated follow-up ≥ 3 months post-operatively, and 225 (52.8%) had returned for any prior post-operative examination. Uncompensated follow-up at ≥ 3 months was associated with higher income (P = 0.037), and recalling instruction by a doctor to follow-up (P = 0.001), while age, gender, travel cost, and post-operative satisfaction and vision were not associated. Younger (P = 0.002) patients and those reporting being instructed to follow up (P = 0.008) were more likely to return for the compensated research examination. Among all interviewed subjects, only 170 (39.9%) reported knowing they were to return to hospital.

CONCLUSIONS:

Modest compensation, advertisements and telephone contact can increase medium-term follow-up rates after cataract surgery by three-fold. Better communication of specific targets for follow-up may improve follow-up compliance.