|Year : 2019 | Volume
| Issue : 1 | Page : 7
Prevalence of cataract and barriers to cataract-related care in rural Ecuador
Sila Bal1, Carlos Gonzalez2, Sarah Marjane3
1 Associate Scholar, Center for Global Health, Perelman School of Medicine, University of Pensylvania,Partners for Andean Community Health, Philadelphia, PA, USA
2 In-country Ophthalmologist, Partners for Andean Community Health, Philadelphia, PA, USA
3 Executive Director, Partners for Andean Community Health, Philadelphia, PA, USA
|Date of Web Publication||26-Sep-2019|
Dr. Sila Bal
3400 Civic Center Blvd, Philadelphia, PA 19104
Source of Support: None, Conflict of Interest: None
Introduction: Cataracts remain the leading cause of blindness worldwide. Despite this, there is a lack of information surrounding cataracts in Ecuador. We sought to assess the rate and barriers to cataract-related care in two Ecuadorian communities to identify points of intervention for local and international organizations.
Methods: This was a cross-sectional assessment using a convenience sample of patients seen in clinics run by Fundacion Internacional Buen Samaritano Paul Martel, a local nonprofit providing affordable eye care in Ecuador. Two populations were assessed. Week 1 patients were from the Andean region of Chimborazo (W1) and week 2 patients from Santa Cruz Island, Galapagos (W2). All patients seen were assessed for cataracts. Patients identified as having cataracts completed a six-question survey related to barriers to care. The primary outcomes were the rate of cataracts and the leading barriers to care.
Results: Forty-four total patients during W1 and 1,002 during W2 were seen and screened for cataracts. Mean age (years) was W1 – 44 years and W2 – 42 years. The overall rate of cataracts was 4 (9%) in W1 and 50 (5%) in W2. When stratified by age, the rate of cataracts in individuals aged 50 and over was 21% (W1) and 6% (W2). Forty-six participants with cataracts completed the survey. The major barriers to cataract-related care were cost (n = 26), followed by access (n = 7), and fear of surgery (n = 4).
Conclusions: Our results confirm the high overall rate of cataracts in patients presenting to eye clinics in two distinct communities. We found that cost and access are the main barriers to care. These communities would benefit greatly from care delivery models that bring services close to where individuals live, through partnerships between local and global organizations.
Keywords: Cataract, prevention of blindness, vision
|How to cite this article:|
Bal S, Gonzalez C, Marjane S. Prevalence of cataract and barriers to cataract-related care in rural Ecuador. Pan Am J Ophthalmol 2019;1:7
|How to cite this URL:|
Bal S, Gonzalez C, Marjane S. Prevalence of cataract and barriers to cataract-related care in rural Ecuador. Pan Am J Ophthalmol [serial online] 2019 [cited 2020 Sep 23];1:7. Available from: http://www.thepajo.org/text.asp?2019/1/1/7/267881
| Introduction|| |
Blindness and vision impairment represent significant global public health concerns and an opportunity for low-cost, high-outcome interventions. There are 285 million people that are visually impaired or blind worldwide. Over 90% of these individuals live in low-income settings. This disparity is the result of cost, disproportionate risk exposure, and the global physician shortage.
Poor vision is associated with a high morbidity and a significant decrease in quality of life. Vision impairment directly affects social participation, limiting employment and self-care. As such, it is associated with a high disease burden and significantly impacts quality-adjusted life years. The estimated quality-adjusted life-year losses associated with vision impairment are comparable to or higher than those associated with other major chronic conditions such as diabetes, stroke, myocardial infarction/ischemic heart disease, asthma, and obesity.
Cataracts are the leading cause of blindness in low-middle income countries. Although age remains the biggest risk factor for cataract development, there are additional environmental risks, such as ultraviolet (UV) radiation. Given this risk, the prevalence of cataracts is highest in areas such as Ecuador where individuals spend long hours outdoors and have increased exposure to UV light.
There is a lack of information on the causes of blindness in Ecuador, although research by Cass et al. confirms that cataracts remain the most common cause of vision impairment in Ecuadorian communities. Furthermore, according to the Rapid Survey on Avoidable Blindness 2009–2010, the prevalence of blindness in Ecuador is 5.8%. Yet, there remain significant barriers to eye in rural Ecuadorian regions. Universal healthcare coverage throughout Ecuador aids in alleviating the financial burden of healthcare needs. However, the lack of ophthalmologists, proper facilities, and the increased number of cataracts impact the prevalence of cataract-related blindness in these communities. Furthermore, barriers such as gender have been elucidated, with one group identifying that men have better access to surgical interventions than women.
There is a significant burden associated with blindness and vision impairment in rural communities. An increased understanding of these barriers will provide local and international organizations with the tools necessary to target vulnerabilities in healthcare systems. To the best of our knowledge, no studies have assessed rate and barriers to cataract-related care in rural Ecuadorian communities. As such, we sought to determine the rate of cataracts and the barriers to access to cataract-related care in two Ecuadorian communities.
| Methods|| |
This was a cross-sectional assessment of cataracts and cataract-related barriers to care in rural Ecuador conducted between July 2017 and August 2017.
Participant recruitment and survey procedures
Participants were a convenience sample of patients seen in Fundacion Internacional Buen Samaritano Paul Martel (FIBUSPAM) clinics. FIBSUPAM is a nonprofit organization located in the Chimborazo province of Ecuador that provides affordable eye care to communities throughout the country. Two separate populations were assessed. Part one patients were from the Andean region of Chimborazo, where the permanent FIBUSPAM ophthalmology clinic is located. Part two patients were from Santa Cruz Island in the Galapagos, where there are no ophthalmologists on the entire archipelago. In both locations, all patients reporting to the clinics were evaluated for the presence of cataracts.
Survey participants were those individuals identified as having a diagnosis of cataracts by the in-country ophthalmologist (s). Participants were solicited for enrollment in person during clinic visits. Those individuals that met all inclusion criteria and were interested in participating in survey completion were invited to speak with a study representative and to review the study information. All study material was translated into Spanish. Participants were asked a six-question survey related to barriers to cataract-related care.
The primary outcomes were rate of cataracts and the leading barriers to cataract-related care. The rate of cataracts was identified using descriptive statistics. Sample characteristics, including age and gender, were assessed. Descriptive statistics was used to summarize barriers to eye care access.
| Results|| |
A total of 44 patients in part one and 1002 patients in part two were seen and screened for cataracts. The overall mean age (years) was 72 with range from 2 to 93. The mean age (years) for part one was 44 and for part two was 42. The overall rate of cataracts from part one and part two was 9% and 5%, respectively. When stratified by age, the rate of cataracts in individuals aged 50 and over was 21% in part one and 6% in part two.
Forty-six participants (26 female, 20 male) met inclusion criteria and were invited to complete the survey. Twelve patients reported that this was their first diagnosis of cataracts. All 46 patients reported visual changes. The average length of time that patients reported significant blurring of their vision was 69.1 months.
Thirty-three patients knew of their diagnosis of cataracts. Of those, the average length of time waiting for cataract-related eye care was 41.3 months. The leading barrier to care was cost (n = 26). This was followed by healthcare access (n = 7) and fear of surgery (n = 4). All except for six of the survey participants reported basic government salary.
The mean age (years) of survey participants, stratified by gender was 71 for males and 73 for females. The mean time with significant vision impairment (months) was 74 among males and 65 among females (P = 0.89). The mean length of time waiting for cataract-related eye care was 36 months among males and 44 months among females (P = 0.66). Seven (27%) of the females reported first diagnoses while 5 (25%) of males were receiving a first-time diagnosis [Table 1].
| Discussion|| |
Previous reports from Ecuador focus on the rate of cataract-related blindness rather than the overall rate of cataracts. This limits surgical intervention to individuals who are already blind and suffering from significant vision-related disability. Our results confirm the high overall rate and the significant lag time for cataract-related eye care in patients presenting to eye clinics in two distinct Ecuadorian communities.
The Rapid Assessment of Avoidable Blindness 2009 showed that cataracts account for 74% of blindness in Ecuadorian communities. Our data support the high rate of cataracts among all patients reporting to the FIBUSPAM clinics. UV radiation increases the risk and severity of cataract formation and is now considered a major factor contributing to blindness.,, This risk disproportionately affects individuals with greater exposure, as is seen in mountainous and tropical regions close to the equator. Organizations aimed at targeting eye care in these communities would benefit from programs that target UV-related damage to the lens. Interventions designed to educate community members and distribute protective eyewear would slow, and even prevent sun damage in these regions.
Patients reported an average length of 69.1 months with significant vision impairment before receiving any vision-related care. Of the 31 patients that knew of their diagnosis of cataracts, the average wait time for receiving cataract-related eye care was 41 months. This represents a significant time with unaddressed disability, due to issues of cost and access. Cost and access to ophthalmologists were the most common barriers to receiving cataract-related care. Despite FIBSUPAM's permanent clinic in the Chimborazo province, this region has a high number of indigenous communities, and access to the city is severely limited by transportation. In the Galapagos, although the socioeconomic status of communities is significantly higher than that in Chimborazo, there is no ophthalmologist and patients must travel to the mainland for eye care. Such travel costs several hundred dollars, limiting access to only a select few patients. Many elderly family members from both regions faced added disability-related obstacles.
Recent research suggests that Ecuadorian males have better access to surgical care than females. Although we acknowledge the systemic differences in barriers to care between the genders, our results did not show a statistically significant difference in either length of time with blurry vision or in treatment delay between the two genders.
The strengths of this study include the large sample size and the distribution of participants between two distinct, rural communities in Ecuador. To the best of our knowledge, no study has examined the rate of cataracts and the subjective barriers to cataract-related care in these communities. This information can serve as a starting point for program development aimed at improving eye care in these regions. However, there are important limitations to consider. Our sample was a convenience sample of all patients reporting to FIBUSPAM clinics, limiting external validity. Patients reporting to ophthalmology clinics have already self-selected based on vision needs. Furthermore, our study was conducted over a narrow time period, limiting access to a more representative sample.
| Conclusion|| |
Cataracts are a treatable and oftentimes preventable cause of blindness. Despite this, many rural Ecuadorian communities are unable to access cataract-related care due to cost and access to healthcare professionals. Local and global organizations aimed at reducing cataract-related vision impairment should focus on care delivery models that bring affordable education and services into the communities where individuals live.
Partners in Andean Community Health, FIBUSPAM and Vision Health International.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Crewe JM, Spilsbury K, Morlet N, Morgan WH, Mukhtar A, Clark A, et al.
Health service use and mortality of the elderly blind. Ophthalmology 2015;122:2344-50.
Park SJ, Ahn S, Park KH. Burden of visual impairment and chronic diseases. JAMA Ophthalmol 2016;134:778-84.
Cass H, Landers J, Benitez P. Causes of blindness among hospital outpatients in Ecuador. Clin Exp Ophthalmol 2006;34:146-51.
Cullen AP. Ozone depletion and solar ultraviolet radiation: Ocular effects, a United Nations environment programme perspective. Eye Contact Lens 2011;37:185-90.
Norval M, Lucas RM, Cullen AP, de Gruijl FR, Longstreth J, Takizawa Y, et al.
The human health effects of ozone depletion and interactions with climate change. Photochem Photobiol Sci 2011;10:199-225.
Rolán DV, Lopez MM, Cuberas-Borrós G, Cuñat JL, Hervás JV, Vilamajó AM, et al.
Neurological symptoms following exposure to ozone. J Neurol 2012;259:2740-2.