Barriers related to the uptake of cataract surgery and care in Limpopo province, South Africa: Professional Ophthalmic Service Providers’ perspective

Studies in South Africa showed that cataract was the second leading cause of blindness and the leading single cause of severe visual impairment. People living in the rural and remote areas of the world are usually of lower socio-economic status and therefore lack the opportunity to utilize eye care services adequately which could result to lack of knowledge regarding cataract surgery. The primary aim of the current study was to increase a better understanding of eye health inequalities in Limpopo province with specific reference to cataract surgery and care. The study sought to answer a central question “What are the barriers related to the uptake of cataract surgery and care in Limpopo. Methods This study used qualitative and descriptive designs through exploring barriers related to the uptake of cataract surgery and care from professional nurses’ perspective. The target population comprised of 20 ophthalmic supportive staff. A non-probability, purposive sampling was applied to select three hospitals in which cataract surgeries are performed. All the 20 ophthalmic supportive staff purposively comprised the sample of the study. Data were collected through Focus Group Discussions. The Tesch’s principles as a guide for classifying data into themes and sub-themes applied. Ethical consideration and trustworthiness for data quality were explained. The study found that patient ignorance, low education and illiteracy, lack of awareness programmes, shortage of ophthalmologist and supportive ophthalmic health professionals, inadequate cataract facilities and resources lead to poor quality services in the hospitals were the major barriers in the uptake of cataract surgery and care.

operations per year. This annual shortfall does not address the backlog of over 35,000 cataract blind people [10].
Vision loss and utilisation of cataract surgery have important demographic and socio-economic determinants. In other words, poverty, for example, and availability, accessibility and utilization of cataract surgery services are cyclically linked, with poverty increasing the risk of inaccessibility to or non-affordability of cataract surgery and therefore increasing the possibility of becoming blind.
Blindness, on the other hand, exacerbates poverty through limiting opportunities to engage in income generating activities [11,18,19,24]. To date, there is no study that has explored the nature of this association among cataract patients in Limpopo province. Proper planning for Vision 2020 blindness prevention programmes in South Africa will only be possible if research evidence on the nature and extent of the problem of the major causes of visual impairment in both the rural and urban areas is known, hence the need for this type of study.

Aim of the study
The goal of the current study was to increase a better understanding of eye health inequalities in Limpopo province with specific reference to cataract surgery and care. The study sought to answer a central question "What are the barriers related to the low uptake of cataract surgery and care in Limpopo?"

Methods
This study used Qualitative and descriptive designs based on the exploring barriers related to the uptake of cataract surgery and care from professional nurses' perspective in Limpopo province, South Africa. The target population comprised of 20 ophthalmic supportive staff, included 3 registered ophthalmic nurses and registered eye specialists. Non probability purposive sampling was applied to select three hospitals in which cataract surgeries are performed. All the 20 ophthalmic supportive staff purposively comprised the sample of the study. Data were collected through Focus Group Discussions (FGDs) for participants to respond to the central question "What are the barriers to the uptake of cataract surgery and care in the health care services?" The sample implies that three focus groups were formulated as follows: hospital A had six (6) participants; hospital B and C had eight (8) and six (6) participants respectively. Data were collected from April to November 2018. The FGDs

Emerging themes
The following themes emerged from the responses that Professional Ophthalmic Service Providers gave.

Barriers related to patient ignorance, low levels of education and lack of awareness programmes
Professional nurses perceived patient ignorance, low education and lack of awareness programmes in the communities on the disease contribute to poor uptake of cataract surgery and care in the rural communities. Some participants indicated that in most situations patients regard impaired vision related to old age and it is normal as one grows to gradually become blind. Participants further said that patients are not keen to visit eye care services because they would travel long distances and sometimes needing escorts. Participants felt that although the majority of patients receive social grants from the government, the money is not enough to access health services, therefore, patients place providing food as number one priority in the family. Participants perceived lack of awareness programmes in the primary health care in particular having a negative impact in the uptake of cataract surgery and care in the rural settings. They regarded the health services in cities and regional hospitals in the towns adequately resourced as compared to health services in the rural settings.
Individual participants supported by the group said: "Lack of awareness and ignorance about the disease contribute to high rates of blindness among the elderlies in the rural communities" "Cultural beliefs that impaired vision and blindness is caused by witchcraft has negative impact in seeking eye care services"

Shortage of ophthalmologist and supportive ophthalmic health professionals
Shortage of ophthalmologist and supportive ophthalmic health professionals was regarded a major barrier in the uptake of cataract surgery and care. In all the three sampled hospitals participants indicated that most health professionals in particular nurses, working in the eye units are not trained eye specialists. The finding is supported by analysing the target population which comprised of 20 ophthalmic supportive staff, with only three registered ophthalmic nurses and one registered eye specialists, implying that the 16 participants were supportive ophthalmic health professionals.
Participants expressed a major concern regarding shortage or absolute lack of ophthalmologists doctors in their hospitals resulting into long waiting list over 2 years and over.
Individual participants supported by the group said: "In our province resources are not adequate as we only have one doctor for cataract surgery who caters for most of the hospitals around Limpopo province." "We have few doctors and equipment as well as facilities." "There is one ophthalmologist for a long list of patients" "The cataract surgical list increases yearly resulting from backlog." "Cataract surgery is a free service to all pensioners but the wait time is a major barrier".

Inadequate cataract facilities and resources lead to poor quality services in the hospitals.
Most participants raised their frustrations regarding the inadequate cataract equipment and facilities to conduct cataract surgery most importantly in the three hospitals responsible for providing the surgery and care in the study setting, the Vhembe district in Limpopo. In one particular focus group overwhelmingly participants voiced the lack of space and poor infrastructure to conduct cataract surgery and care of patients postoperatively.

Individual participants supported by the group said:
"South Africa is having poor cataract care resources, compared to other developing countries, Cataract surgery rate is slow." "Generally, there is lack of resources for eye care in South Africa and is like it originated back from apartheid era, however, we are not treated equal by the government. We suffer most in the remote and rural health services".
"Towns and cities have got human and material resources although is not enough as those centres are catering for a lot of patients".

Discussion
The current study revealed the major barriers such as patient ignorance and low education and lack of awareness programmes; shortage of ophthalmologist and supportive ophthalmic health professionals and inadequate cataract facilities and resources led to poor quality services in the hospitals contributing to low uptake in the cataract surgery and care. These barriers in the uptake of cataract surgery and care have been reported in many studies mostly the developing and underdeveloping countries with a major economic burden such as South Africa [22,23]  The current study found that there were shortage of ophthalmologist and supportive ophthalmic health professionals in the sampled hospitals. Inadequate staff mixed ratio of surgeons to ophthalmic nurses at tertiary hospital in Limpopo was found in the study by Fasasi and Ayanniyi in 2018 [32]. The authors reported that health workers were reluctant to undergo trainings related ophthalmic speciality [32]. The current study further revealed that shortage of manpower and poor referral services also added to the professional nurses' frustration. It is postulated that patients who wait more than 6 months to 2 years and over for cataract surgery may experience negative outcomes during the wait period, including vision loss, a reduced quality of life and an increased rate of falls [28,33].
The participants in the current study linked non-utilisation of cataract care and surgical services to financial constraints. They indicated that patients had to travel long distances to access the services. It is widely reported in literature that people living in the rural and remote areas of the world are usually of lower socio-economic status and therefore lack the opportunity to utilize eye care services adequately. This can be due to non-availability, non-accessibility, non-affordability or lack of knowledge of the available services [5]. The scarcity of eye services in rural areas not necessarily the cost to surgery, could imply that health inequality in surgical treatment is still major barrier in South Africa. Whereas, to date there are countries that have realised the "Vision 2020, THE RIGHT TO SIGHT" initiative of the WHO and International Agency for prevention of Blindness. Various studies reported the rapid increase in the availability of quality cataract surgical services such as the United States and in Latin America, 10 countries have an increase rate that is greater than 100%, and Argentina has highest rate of 264% [15,31].

Conclusion
Cataract removal is the most common and successful ophthalmic surgery globally, however, cataract surgery poses a major economic burden in South Africa and in Limpopo in particular. The findings of the current study are similar to other developing countries. Ignorance, lack of awareness and lack of both human and material resources were found to be the major barriers in the uptake of cataract surgery and care. There is a marked increasing prevalence of blindness in the rural settings and many of the patients are from the disadvantaged socioeconomic backgrounds. The need to increase awareness, health education, early detection and treatment and care may have impact to reduce the risk of blindness. It is evident that the vision 2020 blindness prevention programmes in South Africa if far from being realised therefore, future research beyond 2020 should focus on the nature and extent of the problem of the major causes of inequality to access to cataract surgery and care in both the rural and urban areas.

Abbreviations
The study was approved by the Ethics Research Committee of the University of Venda (Ethical