Dr. Suraj Bhagde, B12851
Bhagde S1, Wagle R2, Bauer S3
Consultant Ophthalmologist, Department of Ophthalmology1, BhaktiVedanta Hospital and Research Institute, Mira Road, Thane, India
Consultant Ophthalmologist, Department of Ophthalmology2, Barsana Eye Hospital, Barsana, India
Social Welfare Organization3, New Vrindavan, West Virginia, United States of America.
Corresponding Author:
Dr. Suraj Bhagde
Consultant Ophthalmologist,
Department of Ophthalmology,
BhaktiVedanta Hospital and Research Institute,
Mira Road, Thane.
Contact number: +91-9833547425
Email id: suraj.bhagde@rediffmail.com
Acknowledgements:
We thank the Medical Research Department of BhaktiVedanta Hospital and Research Institute, for their assistance in the manuscript preparation.
Declaration:
The authors declare that there is no financial interest, no proprietary interest and no conflict of interest related to this submission.
This submission has not been published anywhere previously and it is not simultaneously being considered for any other publication.
Running Head:
A KAP Study about Senile Cataract in Rural India
Abstract:
Background:
A large proportion of cataract patients in rural India are untreated. Evidence indicates lack of awarenessand attitudinal barriers contributing for this backlog. Hence the present study was assessed the knowledge, attitude and practice regarding cataract surgery amongst rural patients who had attended a surgical eye camp.
Methods:
A structured, pre-validated questionnaire was administered to cataract patients from a surgical eye camp at Barsana, India. There were 13 items in the questionnaire assessing their awareness, perception, attitude and practice in regard to undergoing cataract surgery. Chi-square test for independence was used for analysis.
Results:
We enrolled 294 participants. Only 139 {47.3 [41.5, 53.2]} were aware of cataract. A wrong attribution of diminished vision to various other factors was noted in 130/294 {44.2% [38.5, 50.1]} participants. A significant proportion of females {59% [51.2, 67]} and illiterates {57.3% [50.7, 63.6]} were either unaware or attributed to wrong factors, than males {46.3% [38.5, 54.3]} and literates {38.2% [28.1, 49.4]} respectively (P < 0.05). A large proportion – 124/294 {42.2% [36.5, 48.1]} had no idea about the treatment of cataract (P <0.05) and illiterates were more significantly unaware – 109/124 {88% [80.6, 92.8]} (P< 0.05).
Conclusion:
The results of this study indicate that a large number of patients in the rural area have poor insight in their eye condition and depict incomplete and/or incorrect perceptions and practice regarding cataract and its treatment. Therefore the rural population needs to be sensitized and educated for achieving the goals of cataract programs in the country.
Keywords: Awareness, KAP, Cataract, Rural, Questionnaire
Introduction:
India carries a significant proportion of world’s blindness with nearly 6.7 million blind people in the country.[1] Of these, cataract is the main reason for avoidable blindness in the adult population. Studies conducted in various parts of the country have established that cataract is one of the reasons for pushing individuals to poverty and a poor quality of life.[2] Estimates reveal that around 58% of the older population in north and 53% in south India were suffering from non-operated cataract.[3] One of the major reasons for such a high estimate of not undertaking any treatment is poor uptake of the health care facilities especially for people from rural parts of India.[4]Lack of awareness and attitudinal barriers regarding cataract surgery have also been the suggested causes amongst the rural Indian patients.[5] Hence, the present study was envisaged to assess the awareness, attitude and practice regarding cataract amongst the rural patients diagnosed as having senilecataract.
Methods:
Ethics and study participants:
The study was conducted in January and February 2013 after obtaining approval from BhaktiVedanta Hospital Ethics Committee and written consent from all the study participants. The study participants are those patients diagnosed as having cataract in the annual cataract surgery eye camp held in January-February 2013 in Barsana village in the district of Mathura, Uttar Pradesh, India. Patients who were unable to comprehend the questions and those with a past history of cataract surgery were excluded.
Study procedure:
A structured questionnaire that was validated previously[6]and revalidated in a small sample of the same population was used for the study. The eligible participants were administered this questionnaire containing a total of 13 items. Demographic details such as age, sex and literacy status were also noted for each of the participants.
Statistical analysis:
The responses were categorized and represented in proportions with 95% confidence intervals {[]}. Chi-square test was used for the analysis of significant difference in the proportions between literates and illiterates, either gender and individuals aged more than 60 years with younger aged. All the statistical analysis was done with GraphPadInstat 3.0, 1998, Graphpad software Inc. SanDiego, California, USA, www.graphpad.com.
Results:
Demographic details:
A total of 310 patients were approached for the study and 294 consented to participate. Of these 294 participants, 151 were males and 143 were females. The mean (SD) age (in years) of the participants was 63(9.3). Majority [220/294 (74.8%)] of the participants were illiterate while [74/294 (25.2%)] had completed at least their primary schooling.
Responses to the questionnaire:
The overall response to each of the items in the questionnaire with their 95% confidence interval is depicted in Table 1. The details of the individual items are grouped as follows:
1.Knowledge/awareness about cataract:
Of the total 294 participants, only 139 {47.3% [41.5, 53.2]} were aware of cataract. A wrong attribution of their diminished vision to various other factors was noted in 130/294 {44.2% [38.5, 50.1]} of the study participants. A significant proportion of females {59% [51.2, 67]} and illiterates {57.3% [50.7, 63.6]} were either unaware or attributed to wrong factors, than males {46.3% [38.5, 54.3]} and literates {38.2% [28.1, 49.4]}respectively (P < 0.05). Additionally, a significant number of male individuals {60.1% [52, 67.8]} came to know that they had cataract from a proper reliable source (P < 0.05). Majority of the individuals – 175/294 {59.5% [53.7, 65.1]} did not know the reason for them to acquire cataract. No significant differences were observed for this response between the individuals of either sex, literacy state or elderly and people with less than 60 years of age. A large proportion – 124/294 {42.2% [36.5, 48.1]} of the patients had no idea about the treatment of cataract (P <0.05) and illiterates were more significantly unaware – 109/124 {88% [80.6, 92.8]} (P< 0.05). Surprisingly, 247/294 {84.9% [80.1, 88.7]} of the study participants correctly knew that they might have to wear spectacles post surgery. Also, most of the participants – 216/294 {73.5% [67, 83]} either did not know or incorrectly knew about the duration of restrictions that have to be followed after cataract surgery.
2.Attitude:
A total of 172/294 {58.5% [52.6, 64.2]} study participants opined that they would like to be treated in the late stage of cataract advancement. A majority – 115/294 {39.55% [33.9, 45.4]} of the study participants, especially illiterates – 93/115 {80.9% [72.3, 87.4]} said that they would get operated during the winter season. A total of 77/294 {26.5% [21.6, 32]} liked to be placed with an intraocular lens. Also, 150/294 {54.2% [48.1, 60.1]} study participants, especially illiterates – 115/150 {76.7% [68.9, 83]} did not get operated as they were waiting for a free camp with a repute of having good surgical results to be organized.
3.Practice:
A vast majority – 269/294 {92% [88.3, 94.8]} of the study participants did nothing to postpone the onset of cataract while a significant proportion of male individuals {77.3% [54.2, 91.3]} opined that they would undertake some medical treatment to prevent so. When questioned about the types of modifications the patients would take in their daily routine, many individuals – 155/294 {37.4% [32.8, 42.3]} said that they would undertake diet-related measures, while 115/294 {27.8% [23.6, 32.4]} would consider a change in their daily routine activity.
Discussion:
Of the many diseases in the elderly, cataract is one of the commonest problems and it poses a sizeable disability on the individual. The blindness that ensues imparts a limitation which is not just physical, but also psychosocial and economic in nature. Cataract is the most common cause of preventable blindness accounting for nearly 67% of the total cases.[7] One would assume that a person suffering from such disability would want to get rid of the condition as soon as possible. Sadly, this is not to be seen especially in rural India. The impediments in achieving a good cataract surgery rate in many Indian states appear to be coming from the rural areas. In many areas, the barriers are mainly constituted by limited facilities, both in terms of availability of cataract surgery centers with sufficient infrastructure and also availability of skilled manpower like ophthalmologists and ophthalmic paramedical assistants. However, in areas, which provide access to eye care facilities, the main impediments are constituted by poor uptake rate of such facilities.[5]A study similar to ours but done in the past in Haryana,[6] a state with literacy rate of around 55% elicited a few similar characteristics of unawareness regarding the cataract and its treatment. In the earlier study,[6] patients with cataracts, pseudophakia as well as aphakia were included. However, in the present study, we have included only the nascent population, which has not undergone any previous eye surgery. We believed that any exposure to the eye care system during any previous cataract surgery would have exposed them to knowledge and awareness about cataract and its management. This would have biased their opinion in the current questionnaire study. Also, the questionnaire of each person was conducted in seclusion from all others so as not to sensitize the others regarding any awareness item. Hence, the degree of awareness prevalent in the rural population is brought out in its unbiased state in the current study. Dismal awareness parameters that were noted were such as i.) No knowledge that cataract is to be anticipated as a part of ageing process (59.5%); ii.) No knowledge that cataract is treated by an eye surgery (42.2%) and iii) preference to delay the treatment of cataract up until the late stages (58.5%) do not augur good news for all the crusaders in the vision 2020 program.
Many preventive programs have been initiated throughout the world to enable earlier identification of cataract and offer appropriate management. For these programs to be successful, people should be aware and should be free of any misconceptions. For example, a recentdoor-to-door study of a district in Maharashtra had estimated that despite many strategies such as increasing the cataract surgical coverage, the awareness remains similar over many years.[8] Even studies from other parts of the world had similar figures.[9-12] Patients were not willing to undergo surgical correction for cataract due to the fear of surgery.[11,13]However, the condition seems to have improved and none such reason has featured in the present study upon asking the subjects about their reason to delay their cataract treatment. Another major barrier is the seasonal preference of majority (88%) of the Indian rural population to get operated mostly in winter or in rainy season. This trend leaves the 4-6 months of summer and early part of rainy season unproductive from the point of view of reducing the cataract load in the community. Simultaneously, the resources are strained during winters to handle the rush of patients willing for the cataract surgery. This trend can be effectively reversed by educating and encouraging the people to get operated in summers also and not be fearful of any adverse effects as was shown by a previous experience in a rural area of West Bengal.[14] All these and many other problems are compounded by high rates of illiteracy in rural areas which is found more in women compared to men.
The study is limited by the fact that it was conducted in patients from a single camp, economic impact was not assessed and no follow-up of the study participants was done.However, as a goodwill and ethical gesture, the misconceptions of all the participants were rectified individually after their questionnaire was over. The findings of the study necessitates a multidisciplinary approach wherein despite the easy availability of centers offering care to prevent cataract-related blindness under the national program, private practitioners, both government and non-governmental organizations should take steps to improve the awareness of cataract especially in the rural masses. To conclude, the results of this study indicate that a large number of patients in the rural area were unaware of the correct knowledge and practices regarding senile cataract and therefore need to be educated for achieving the goals of cataract programs in the country.
References:
- Resnikoff S, Pascolini D, Etya’ale D, Kocur I, Pararajasegaram R, Pokharel GP, et al. Global data on visual impairment in the year 2002. Bull World Health Organ2004;82:844–51.
- Khanna R, Raman U, Rao GN. Blindness and poverty in India: the way forward. ClinExpOptom2007;90:406-14.
- Vashist P, Talwar B, Gogoi M, Maraini G, Camparini M, Ravindaran RD, et al. Prevalence of cataract in an older population in India. Ophthalmology 2011;118:272-78.
- Finger RP, Ali M, Earnest J, Nirmalan PK. Cataract surgery in Andhra Pradesh state, India: an investigation into uptake following outreach screening camps. Ophthalmic Epidemiol 2007;14:327-32.
- Dhaliwal U, Gupta SK. Barriers to the uptake of cataract surgery in patients presenting to a hospital. Indian J Ophthalmol. 2007;155:133-6.
- Bhagwan J, Rastogi IM, Malik JS, Dhull CS. Knowledge, attitude and practices regarding cataract surgery among senile cataract cases in Haryana. Indian Journal of Community Medicine 2006;31:66.
- Government of India, National Survey on Blindness and Visual Outcome after Cataract Surgery, 2001-2002, vol. 77, National Programme for Control of Blindness, Ministry of Health, Government of India, New Delhi, India, 2002.
- Limburg H, Vaidyanathan A, Pampattiwar KN. Cataract blindness on the rise? Results of a door-to-door examination in Mohadi. Community Eye Care 1996;44:241-44.
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Table 1. Summary of the responses to the questionnaire (n=294)
| Questionnaire items | Responses (Interpreted) | Frequency {percentage [confidence intervals]} |
| Do you know what does cataract mean? | No | 25 {8.5 [5.7, 12.4]} |
| Yes | 139 {47.3 [41.5, 53.2]} | |
| Said yes, but there was an attribution to wrong factors | 130 {44.2 [38.5, 50.1]} | |
| Who told you that you had cataract? | Don’t know | 118 {40.1 [34.5, 46.1]} |
| Proper source | 158 {53.7 [47.9, 59,5]} | |
| Hear say | 18 {6.1 [3.8, 9.7]} | |
| What do you think is the reason for you to get cataract? | Don’t know | 175 {59.5 [53.7, 65.1]} |
| Had insight – right reasoning | 65 {22.1 [17.6, 27.4]} | |
| The reasoning was wrong | 54 {18.4 [14.2, 23.4]} | |
| What did you think was the treatment for cataract? | Don’t know | 124 {42.2 [36.5, 48.1]} |
| Mentioned Surgery | 164 {55.8 [50, 61.5]} | |
| Wrong attribution | 6 {2 [1, 4.6]} | |
| When do you feel is the ideal time to undergo cataract surgery? | Don’t know | 100 {34 [28.7, 40]} |
| Early | 5 {1.7 [0.6, 4.2]} | |
| Late | 172 {58.5 [52.6, 64.2]} | |
| On time | 17 {5.8 [3.5, 9.3]} | |
| How long should one follow restrictions after cataract surgery? | Don’t know | 76 {25.9 [21, 31]} |
| Correct knowledge | 78 {26.5 [21.7, 32]} | |
| Incorrect knowledge | 140 {47.6 [41.8, 53.5]} | |
| Will you requireuse of spectaclesafter cataract surgery? | Don’t know | 33 {11.3 [8, 15.7]} |
| Correct knowledge | 247 {84.9 [80.1, 88.7]} | |
| Incorrect knowledge | 11 {3.8 [2, 6.9]} | |
| In which season would you like to get operated? | Don’t know | 19 {6.5 [4, 10.2]} |
| Winter only | 115 {39.5 [33.9, 45.4]} | |
| Anytime | 16 {5.5 [3.3, 9]} | |
| Not in summer | 141 {48.5 [42.6, 54.3]} | |
| Would you like an intraocular lens to be put inside your eye? | Don’t know | 133 {45.7 [40, 51.6]} |
| Correct knowledge | 77 {26.5 [21.6, 32]} | |
| Incorrect knowledge | 2 {0.7 [0.1, 2.7]} | |
| As per doctors advice | 4 {1.4 [0.4, 3.7]} | |
| Did you do something to postpone the onset of cataract? | Nothing | 269 {92 [88.3, 94.8]} |
| Medical treatment | 22 {7.5 [4.9, 11.3]} | |
| Home-based remedy | 1 {0.3 [0, 2.2]} | |
| Have you visited any other camp/hospital for cataract? | Yes | 245 {83.9 [79.1, 87.8]} |
| No | 47 {16.1 [12.2, 20.9]} | |
| Why did you not get operated till now? | Can’t say | 24 {8.7 [5.7, 12.8]} |
| Waiting for this camp | 150 {54.2 [48.1, 60.1]} | |
| Eye related factors | 88 {31.8 [48.1, 60.1]} | |
| Ancillary factors | 15 {5.4 [3.2, 9]} | |
| What modification will you make in your daily routine after cataract surgery? | Don’t know | 91 {22 [18.2, 26.3]} |
| Diet related | 155 {37.4 [32.8, 42.3]} | |
| Activity related | 115 {27.8 [23.6, 32.4]} | |
| Habits related | 24 {5.8 [3.8, 8.6]} | |
| Protective measures for eyes | 29 {7 [4.8, 10]} |