Factors associated with the uptake of cataract surgery and interventions to improve uptake in low- and middle-income countries: A systematic review

Author: Mailu EW, Virendrakumar B, Bechange S, Jolley E, Schmidt E.

Geographical coverage: Asia and Africa

Sector: Service Delivery

Sub-sector: Access, uptake

Equity focus: Not reported

Study population: Patients with cataract

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Not applicable

Background: Cataract remains the leading cause of global blindness, disproportionately affecting women, individuals from low- and middle-income countries (LMICs), and those living in poverty. Although cataract surgery is cost-effective and enhances quality of life, uptake in these regions remains low. This is largely due to supply-side barriers such as inadequate infrastructure, and demand-side challenges including fear, limited awareness, and difficulties related to travel. Traditional demand–supply frameworks in healthcare underscore the importance of targeted service design. Despite substantial evidence on the barriers to access, there is limited understanding of effective strategies to enhance uptake and utilisation.

Objective: To synthesise all available literature on the uptake of age-related cataract surgery and the specific factors associated with uptake and interventions aiming to improve it

Main findings: The review included seven studies, two randomised controlled trials (RCTs) and five observational studies. Studies reported data from four Asian countries including China (n = 2); India (n = 2); Bangladesh (n = 1); and the Philippines (n = 1); and three African countries: Ghana (n = 1); Madagascar (n = 1); and Kenya (n = 1). Data from Kenya, Bangladesh and the Philippines were collected in one multi-country study. The studies varied in methodological quality, with two RCTs assessed as having a low risk of bias, four studies rated as medium risk, and one cohort study classified as high risk of bias.

Cataract surgery uptake (CSU) varied widely across the settings, ranging from as low as 14.4% in a control group in China to as high as 91.7% in a district outreach programme in Southern India. Notably, the highest uptake rates were consistently observed in outreach-based programmes in India.

Factors associated with cataract surgery uptake were categorised into four broad groups: demographic and socio-economic characteristics, cost and distance to health facilities, vision and health status, and perceptions of service quality and opinion of others. Gender disparities were evident, with men generally more likely to undergo surgery in some settings (e.g., China, Kenya, and Bangladesh), although other studies found no significant gender differences. Age also influenced uptake, with younger individuals (50–60 years) more likely to accept surgery than those over 70. Socioeconomic status, education, occupation, and residence showed inconsistent associations with uptake. Patients with poorer vision were more likely to undergo surgery in some contexts. General health status and comorbidities showed no consistent association with surgery uptake. However, knowledge that surgery is the only treatment option was linked with increased uptake (odds ratio [OR]: 1.83; 95% confidence interval [CI]: 1.07–3.13).

Cost emerged as a critical barrier. One RCT demonstrated that offering free surgery significantly improved uptake compared to low-cost surgery (31.1% vs 14.4%, P = 0.012). In observational studies, anticipated loss of income was weakly associated with higher uptake (OR: 1.36; 95% CI: 1.01 to 1.83), and patients from closer districts had a significantly higher uptake (risk ratio [RR]: 1.8; 95% CI: 1.1 to 3.2). However, associations with other cost-related factors such as user fees, transport distance, or general out-of-pocket spending were inconsistent across settings.

Overall, the review highlighted the variability of cataract surgery uptake across LMICs and identified a complex interplay of factors influencing decisions. It also noted a significant evidence gap regarding effective interventions, especially those addressing structural and gender-related barriers.

Methodology: The searches were conducted in Medline, Embase, CENTRAL, LILACS, and ISRCTN to identify studies conducted on participants with cataracts and containing primary data on uptake of surgery. The review included the studies conducted in LMICs and published in English, Portuguese and French after 2000. Furthermore, reference lists of the included studies and relevant review articles were scanned to identify additional relevant publications.

Two reviewers independently screened the articles, extracted the relevant data, and assessed the methodological quality of the included studies. Discrepancies were resolved through discussion. The study quality was assessed using an appropriate Critical Appraisal Skills Programme (CASP) checklist for each study design. The findings were synthesised narratively.

Applicability/external validity: The review highlighted that uptake of cataract surgery varied widely between settings due to differences in population characteristics, programme design, and local health system contexts. This variability limits how universally the findings can be applied without considering local nuances. In addition, the review authors noted that many included studies were based on outreach programmes, which often serve relatively homogeneous, disadvantaged populations, making the findings less generalisable to other healthcare delivery models (e.g. facility-based care). Furthermore, the review emphasised the role of gender disparities and socio-cultural factors in shaping access to surgery, suggesting that strategies effective in one context may not be translated well to others without careful adaptation to local norms and barriers.

Geographic focus: The review was focused on the studies conducted in LMICs. The included studies were conducted in Asian and African countries.

Summary of quality assessment: Overall, there is medium confidence in the review’s conclusion. The review employed a comprehensive search strategy with clearly defined inclusion and exclusion criteria. Two reviewers independently screened articles, extracted data, and assessed the methodological quality of the included studies. Risk of bias was evaluated using established tools, and the findings were reported accordingly. Study characteristics were thoroughly documented, and results were synthesised narratively. Heterogeneity across studies was acknowledged and discussed. However, the review did not provide a list of excluded studies, and the search was limited to articles published in English, Portuguese, and French. Additionally, the review did not present findings stratified by risk of bias status.