Vision loss, access to eye care and quality of cataract surgery in a marginalised population : The Karachi Marine Fishing Communities Eye and General Health Survey

Abstract

Background Marine fishing communities are among the most marginalised and hard-to-reach groups; health research with these communities is time-consuming, expensive and unpredictable given that most male members are at sea for lengthy periods. Objectives and methods The Karachi Marine Fishing Communities Eye and General Health Survey was a cross-sectional study among fishing communities living on three islands and in four coastal areas in Karachi, on the coast of the Arabian Sea. The survey examined gender, ethnic and socioeconomic differences in the burden of vision loss, access to eye care services, user experiences, and outcomes of cataract surgery. Data were collected between March 2009 and April 2010: informants participated in a detailed interview regarding their sociodemographic characteristics, eye care use and experiences, were tested for presenting and best-corrected visual acuity with a reduced logMAR chart, and underwent detailed eye examination. Key findings Of 700 participants (49.4% males) aged ≥ 50 years planned to be included, 638 (91.1%) were interviewed and examined. Nearly all (93.9%, 95% confidence interval [CI], 91.7% 95.6%) lived in extreme poverty and 84.3% (81.3%-86.9%) had no school-based education. The age-standardised prevalence of mild vision impairment (VI; presenting visual acuity <6/12-6/18 in the better eye), moderate or severe VI (MSVI; <6/18-3/60) and blindness (<3/60) were 15.1 % (12.2%-17.9%), 23.2 % (19.8%-26.5%), and 2.8% (1.4%-4.2%), respectively. Women had markedly poorer vision. Cataract accounted for 62.5% of all blindness and 54.7% MSVI while uncorrected refractive errors accounted for 30.7% and 70.3% of MSVI and mild VI, respectively. Overall, 349 (54.7%; 95% CI 50.8%-58.6%) participants had never had an eye examination. Ethnic Bengalis were 4.2 times less likely (odds ratio 0.24, 95% CI 0.15 0.38; P<0.001) to have had an eye examination in the past than Kutchis. Bengalis compared with Kutchis and Sindhis, and individuals describing their household financial status as poor/fragile compared with fine were more likely to cite financial hardships as barriers to the uptake of eye care, while women were more likely to cite financial hardships, fears and social support constraints than men. Bengalis had markedly lower cataract surgical coverage than other ethnic groups. Acceptability of eye care services in this marginalized population, especially among women, was low. Of those who had used eye care services within the last 5 years (n=218), 43.1% (36.7%-49.76%) reported unwillingness to visit again their last visited care facility or to recommend this service to others. Women were two times more likely to voice such concerns compared with men, especially about financial inaccessibility, ineffectiveness of care and poor communications by staff. Women s eyes were 4.38 times more likely to have suboptimal visual outcome (PVA<6/18) compared with men s eyes (adjusted odds ratio 4.38, 95% CI 1.96-9.79; P<0.001) after adjusting for the effect of household financial status. However, women did not voice their dissatisfaction with the outcome as frequently as men. Implications Vision impairment and blindness are receiving attention globally but with insufficient focus on those most difficult to reach and having unequal access. This study provides the first detailed description of large unmet needs of a hard-to-reach, marginalised population in Karachi, despite the adverse security situation. These communities, especially women and ethnic Bengalis, require proactive attention in policy, service delivery, and research.