Female gender: A significant barrier to access cataract surgery in rural Gurugram,Haryana,India

Abstract

The goal of this study is to determine whether the female gender is a barrier for the access to cataract surgery in the rural population of Gurugram district, Haryana, India.

The data of consecutive 100 male and 100 female patients operated for cataract surgery at Department of Ophthalmology, University-affiliated hospital were studied. Data pertaining to age of the patients, visual acuity of the operated and better eye, maturity of the cataract at time of surgery, type of cataract surgery opted were analysed. Visual impairment was considered when visual acuity of the better eye was less than 6/18 (0.32).Two types of cataract surgery were offered to the patients: manual small-incision cataract surgery (SICS) and phacoemulsification. Independent t-tailed test was used to analyse data to ascertain female gender as a barrier to access cataract surgery.

The findings indicate that the difference in age at the time of surgery between men and women was not statistically significant (p = .327). The analysis of visual impairment in the operated eye of men and women was also not statistically significant (p = .173). However, the analysis of visual impairment in the better eye was strongly suggestive of gender bias with statistically significant results (p = .001). In total, 71% male and 56% female patients opted for phacoemulsification surgery, whereas 44% women and 29% men chose less-expensive manual SICS surgery.

The study indicates that females had severe visual impairment in the better eye at the time of surgery and also opted for a less-expensive option indicating less financial freedom and decision-making power.

Keywords

Cataract gender visual impairment

Introduction

Blindness is a global public health concern. Almost 36 million people were estimated to be blind in 2010 and this number is expected to rise to approximately 114 million by 2050 (Lou et al., 2018; Prasad et al., 2020). The leading causes of visual impairment include cataract, uncorrected refractive error, and diabetic retinopathy. Cataract, though easily treatable, remains an important reason for blindness with 10.9 million being blind and 35.1 million with moderate and severe visual impairment according to the Global Burden of Diseases (GBD) Study 2010 (Bourne et al., 2013; Khairallah et al., 2015; Pascolini & Mariotti, 2012). The proportion of women with blindness and moderate to severe visual impairment is higher than men across the globe. According to Lancet study of 2017, the relative odds ratio of visual impairment due to cataract among men versus women is 1.21 (80% uncertainty interval UI: 1.17–1.25) (Seth et al., 2017).

South Asia with its 12 million blind and 61 million with moderate and severe visual impairment contributes maximum numbers to global blindness burden (Bourne et al., 2017). In addition, from 1990 to 2010, the blindness expansion rate for females was four times higher than in males (Jonas et al., 2014). India records the highest prevalence of visual impairment in South Asia region with 4% blind and 17% moderate and severely visually impaired among its adult population (Bourne et al., 2017). In 1976, India was the first country to launch the National Programme for Control of Blindness. The goal was to reduce the prevalence of blindness to 0.3% by the year 2020. India has undergone fundamental transitions in society and economic growth, yet the incidence of preventable blindness remains high among rural and marginalized sections of society including women (National Programme for Control of Blindness, 2019).

Gender remains a significant barrier in uptake of cataract surgical services around the world. It has been observed that women had poorer visual acuity and waited longer to avail cataract surgery than men even in developed countries (Jonsson et al., 2006; Lundqvist & Mönestam, 2008). This gender divide in low- and middle-income countries is glaring with men being 1.7 times more likely to undergo cataract surgery than women (Abou-Gareeb et al., 2001; Lewallen et al., 2009). Worldwide women have a higher cataract burden than men and the similar trends are seen in India as well. A meta-analysis published in 2018 concludes that women were 35% more likely to be blind and 69% more likely to be cataract blind than men in India. The study of the pooled data revealed that about one-third of the prevalence of blindness (35%) and cataract blindness (33%) was attributable to their gender alone (Prasad et al., 2020). A recent meta-analysis study by Prasad et al. reports that cataract surgery coverage was 27% lower in women than men and it could be improved by 133.4% in women if the gender gap in coverage is eliminated (Prasad et al., 2020; Ye et al., 2020). There have been variations in association of gender and visual impairment in different studies depending on the study location and sample size. Two surveys conducted in India, one including 5158 participants by Murthy et al. (2010), showed that the sex difference was not significant, whereas the other including 42,722 participants by Neena et al. (2008) supported the existence of sex differences.

Gender-specific health-seeking behavioural studies have not been done in Haryana. The purpose of this study is to determine gender differences in cataract surgery accessibility in rural areas of Haryana’s Gurugram district. Haryana is a state in northern India where agriculture is the primary source of income for the majority of the population. Haryana has emerged as a well-developed state in less than 40 years, with the third highest per capita income in India (Seetharaman & Katiyar, 2019). Despite economic prosperity, women’s status in society has not improved significantly. This gap is reflected in a 2017 study from the Government of Haryana, which states that only 25.6% of girls had average health. Men own 70% of agricultural land, but women hold only 9% of government jobs and only 3% of corporate jobs (Chahar, 2018). Population-level evidence on vision impairment from rural areas is necessary for optimal eye care service planning. The findings of the study can be considered as indicative of the rural context, providing insight into the barriers to access cataract surgery. India is largely an agrarian economy and rural community, hence the findings can be viewed as representative of the rural context.

Aims and objective

The aim of this study was designed to analyse gender bias in cataract surgery coverage in a rural area of Gurugram, Haryana.

Materials and methods

The data of consecutive 100 male and 100 female patients operated for cataract surgery at the University-affiliated teaching hospital were analysed over 6 months in 2020. The hospital is located in a rural area of Gurugram district and caters to predominantly rural population of Gurugram and its adjoining districts in the state of Haryana. Informed consent was obtained from all patients, and their identity was protected in the study.

Ethics statement

The study followed the tenets of the Declaration of Helsinki and was approved by the hospital ethics committee (SEC/FMHS/F/27/05/21-47).

Data management

This was a hospital-based data analysis of consecutive 100 male and 100 female cataract surgery patients. Socioeconomic data on age, gender, and residence were noted. Vision of the eye to be operated on and of the better eye was recorded using Snellen chart and was converted to decimal notations as prescribed by International Council of Ophthalmology, Report 2002, for ease of data analysis. Visual impairment was defined as per definitions suggested by the World Health Organization (WHO). Visual impairment was considered when presenting visual acuity was less than 6/18 (0.32) in the better eye. Moderate visual impairment was defined as presenting visual acuity <6/18 (0.32) and >6/60 (0.1) in the better eye. Severe visual impairment was defined as presenting visual acuity <6/60 (0.1) and >3/60 (0.05) in the better eye. Blindness was defined as presenting visual acuity <3/60 (0.05) in the better eye. Morphology of cataract in the operated eye was classified using slit lamp in seven main types; pure Nuclear Sclerosis (NS), pure Cortical (C), pure Posterior Subcapsular (PSC), combined NS + C, combined NS + PSC, and combined PSC + C cataract. If the lens was completely opaque, it was classified as a mature cataract (M). This subclassification was based on the recommendations of the American Cooperative Cataract Research Group (Chylack et al., 1984). The lens classifications were conducted by one of the authors. Two types of cataract surgeries are offered at the hospital: manual small-incision cataract surgery (SICS) with rigid intraocular lens (IOL) and phacoemulsification with foldable IOL. The cost of manual SICS is INR Rs. 2500 and phacoemulsification is INR Rs. 5000 which covers the cost of all surgical consumables including the IOL and the medications used during the hospital stay.

Statistical analysis

Age (Table 1): In the study of the 100 male and 100 female patients, the mean age for men and women was 60.90 and 60.20, respectively. This age difference according to independent t-test analysis was not statistically significant (p = .327). Four women and no men in the age group 81–90 and 91–100 had cataract surgery at our hospital during this study. The age distributions of cataract surgery were almost identical for the men and women included in this study.

Table 1.

Age at the time of surgery.

Age (years)	Male patients	Female patients
21–30	1	2
31–40	3	4
41–50	11	14
51–60	32	34
61–70	40	34
71–80	13	8
81–90	NIL	3
91–100	NIL	1

Visual acuity of the better eye (Table 2): The mean visual acuity in the better eye of male and female patients was 0.398 (approximately 6/18) and 0.284 (approximately 6/24), respectively. This difference according to two-tailed t test assuming unequal variances was statistically significant (p = .001). In total, 64% female patients had moderate or severe visual impairment in the better eye at the time of cataract surgery. However, only 37% of men were in the similar category of visual impairment. Also, 7% female as compared to 4% male were in the blindness category at the time of surgery.

Table 2.

Categories of visual impairment in the better eye.

	Vision of operated eye	Male patients	Female patients
Normal	>6/18 (0.32)	59	29
Moderate visual impairment	<6/18 (0.32)–6/60 (0.1)	25	47
Severe visual impairment	<6/60 (0.1)–3/60 (0.05)	12	17
Blindness	<3/60 (0.05)	4	7

Visual acuity of the operated eye (Table 3): The mean visual acuity in the operated eye of male and female patients was 0.111 (approximately 6/60) and 0.097 (approximately 6/60), respectively. This difference according to two-tailed t test assuming unequal variances was not statistically significant (p = .327). In total, 64% female patients had moderate or severe visual impairment in the operated eye at the time of cataract surgery and 65% men were in the similar category of visual impairment. However, 33% female as compared to 29% male were in the blindness category at the time of surgery.

Table 3.

Categories of visual impairment in the operated eye.

	Vision of operated eye	Male patients	Female patients
Normal	>6/18 (0.32)	6	3
Moderate visual impairment	<6/18 (0.32)–6/60 (0.1)	37	29
Severe visual impairment	<6/60 (0.1)–3/60 (0.05)	28	35
Blindness	<3/60 (0.05)	29	33

Morphology of cataract (Table 4): The proportion of various types of cataract is shown in Table 4. The proportion of pure nuclear sclerosis for male and female patients was 52% and 53%, respectively. In the category of combined nuclear sclerosis and posterior subcapsular cataract, the proportion was 26% male and 21% female patients. In total, 17% male and 18% female patients presented with mature cataract.

Table 4.

Morphology of cataract at the time of surgery.

Morphology of cataract	Male patients	Female patients
PSC	5	8
NS	52	53
Combined NS + PSC	26	21
Mature	17	18
Pure Cortical (C)	0	0
Combined NS + C	0	0
Combined PSC + C	0	0

PSC: Pure Posterior Subcapsular; NS: Pure Nucleus Sclerosis.

Type of surgery opted (Table 5): 71% male and 56% female patients opted for phacoemulsification with foldable IOL; 29% male and 44% female patients opted for manual SICS with rigid IOL.

Table 5.

Type of surgery opted.

Type of surgery	Male Patients	Female Patients
SICS	29	44
Phacoemulsification	71	56

SICS: small-incision cataract surgery.

Discussion

Gender inequity in cataract surgery coverage can be attributed to social, economic, and cultural differences. According to various studies, access to cataract surgery services for women continues to be a concern in most parts of the world (Chahar, 2018; Lewallen et al., 2009; Prasad et al., 2019; Rao et al., 2011). Globally, if women had the same access to cataract surgery as males, cataract-related blindness would decrease by around 11%, marking progress in global eye health care (Courtright, 2009).

The cost of cataract surgery may be prohibitive in low- and middle-income countries. This is especially true for females particularly in rural areas. These women frequently have less disposable income or financial control than males, and their ability to receive treatment is constrained by the geographic location of facilities, the charges, and transportation (Lewallen & Courtright, 2002; Malhotra et al., 2018). The similar pattern has been observed in this study. The majority of male patients chose phacoemulsification with foldable IOL, while nearly half of female patients chose manual SICS, which is less expensive. It can be inferred that cost remained a deciding factor in female patients’ decision to get cataract surgery. The study’s findings involving female patients’ late presentation for cataract surgery and less-expensive surgical options highlight the intersection of limited decision-making autonomy, child and family care responsibilities, and a lack of freedom to leave the house. Furthermore, the complex process of decision-making at the family level compels female patients to wait or negotiate support among their family members (Geneau et al., 2005; Nanda, 2002). To ensure the success of blindness prevention initiatives, it is essential to examine the barriers that women experience in accessing cataract surgery.

Limitations of the study

The lack of data on important socioeconomic criteria such as education, income, and occupation, which could potentially influence the results, is a limitation in this study. The quantitative nature of this study prevents access to information that helps us to investigate and comprehend complicated social issues. More research on women’s social, economic, and cultural backgrounds is needed to better understand the dynamics that prevent them from getting cataract surgery.

Conclusion

This study concludes that gender remains a significant barrier in the uptake of cataract surgical coverage in rural parts of Gurugram, Haryana. Despite remarkable improvement in the economic indicators, gender disparity in the uptake of health care is a public health issue. More efforts are needed to increase eye care service utilization by the female population. Gender-specific policy changes are simple interventions to address this issue. A better understanding of factors predicting uptake of cataract services separately for men and women would be useful in addressing the gap.

Recommendations

Gender bias in health care services uptake is a reality. Factors impeding females’ access to cataract surgery should be taken into account when planning and implementing blindness prevention programmes.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Chetna Sharma

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