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The 2019 WHO report on vision puts the number of people globally with visual impairment (VI) or blindness at 2.2 billion, of whom at least 1 billion have a VI that could have been prevented or is yet to be addressed.1 As per the initial estimates of the National Blindness and Visual Impairment Survey of India 2015–2019, the prevalence of blindness in the overall population had decreased to 0.36% in 2019 from an estimated 0.68% in 2010, indicating a 47% reduction in blindness in the country.2,3 Although this decline is encouraging, cataract continues to be the chief cause of untreated blindness accounting for about two-thirds of the blindness burden.2 Effects of cataract and its subsequent surgical treatment on improvements in vision and overall quality of life of patients and a reduction in associated risks such as falls and vehicular crash are well documented.4–12 However, little work has been done to understand the dynamics of mental health outcomes among patients with VI and such studies emanating from India have been few.13–19
Depression is ranked by the WHO as the single largest contributor to global disability (7.5% of all years lived with disability in 2015); anxiety disorders are ranked 6th (3.4%).20 The WHO also estimates that people with VI are three times more likely to suffer from depression and anxiety disorders.21 However, evidence from other parts of the world has produced conflicting results with regard to the relationship of cataract with depression and anxiety.12,22–26 A recent study among the elderly in institutional residential care in southern India has revealed a high prevalence of depression among dual visual and hearing impaired elderly people.27 It is therefore crucial to understand the association between cataract and mental health outcomes so as to guide comprehensive clinical management of cataracts and to generate scientific evidence locally that is relevant to health policy-makers and planners, cataract surgical service providers and eye care professionals. We did a longitudinal study among those identified with cataracts to determine the impact of vision loss due to cataract on mental health before and after surgery. We dwell upon the state of mental health among patients awaiting cataract surgical intervention.
METHODSOur data are sourced from baseline assessment of a longitudinal study that was planned at four tertiary, not-for-profit eye hospitals spread across four northern and western Indian states. Data were collected from May 2018 to June 2019. Ethics approval for this study was provided by the Human Ethics Committee of the Aditya Jyot Eye Hospital, Mumbai, India. Provision was made for referral to a psychologist in the event of distress resulting from the interview for adults who participated in this study.
Study setting and sampleThe study population comprised adults presenting to the ophthalmology department of four tertiary, not-for-profit eye hospitals. They were either walk-in patients or referrals from outreach eye screening camps.
A random-proportional sampling technique was adopted to sample all eligible participants. The sample was proportionately distributed among the four hospitals based on the volume of annual cataract surgeries performed during the preceding financial year. Individuals aged 18 years and above who presented for the first eye surgery with no obvious cognitive or auditory deficits and who could understand at least one of the following four languages—Gujarati, Marathi, Hindi or English—were considered eligible for participation. The calculation of the sample size was based on two prior studies of relevance. Both were longitudinal studies that looked at the impact of cataract surgery on depression symptoms using the Center for Epidemiological Studies–Depression Scale (CES-D) before and after cataract surgery.26,28 The mean depressive symptom scores from these studies decreased from 8.03 before surgery to 7.02 at follow-up.26,28 To observe a similar improvement in depressive symptoms post-surgery with two-sided statistical significance of 5% and 90% power, 632 patients would be required. This was increased to 820 to account for a 30% loss to follow-up in a longitudinal study.
Data collection: BaselineStandard research protocols were followed during data collection in accordance with the Declaration of Helsinki. Patients were recruited at the preoperative inpatient wards wherein beds were laid out in an organized fashion. A systematic listing of the occupants available was undertaken to document their age, whether first-eye cataract surgery, language spoken by them and presence of any cognitive or auditory anomalies were recorded. This information was used to identify the eligible participants for the study. A potential respondent was chosen to participate in the study from every third or fifth bed depending on the sample size required from each hospital, with the first respondent chosen randomly from the sampling interval. Once identified, each potential participant was contacted by an interviewer trained in the study procedures with the assistance of the hospital staff. Before starting the interview, each participant was explained the nature and purpose of the interview and their written informed consent for participation was obtained. Subsequently, participants were interviewed in an isolated area outside the inpatient ward of the hospital. All participants had the right to refuse participation or stop the interview anytime. The average interview time was 45 minutes. Interviews were recorded on paper.
MeasuresThe interview documented sociodemographic characteristics of the patients including age, gender, education, occupation, place of residence, current living arrangements, visual acuity and spectacle use. Details on preoperative visual acuity, type of cataract, comorbid ocular conditions other than cataract, cataract in the fellow eye and eye selected for cataract surgery were extracted from the individual patient medical records available with the treating hospitals.
DepressionThe 20-point CES-D scale was used in the study population, which determined the one-week prevalence of sub-threshold depression.29,30 This scale was previously used to assess depressive symptoms in ophthalmic patients suffering with cataracts including among Indian adult populations.13,17,26,28,31–33
The CES-D was used because it provides an estimate of symptoms appropriate for the goals of an epidemiological study, rather than a diagnostic test or screen for clinical depression.26 This scale was translated into the local languages for use by the researchers, and then was back-translated and field-tested to ensure proper readability. The researchers closely collaborated with mental health experts and the participating hospital staff to achieve the accuracy of cultural understanding and translation. The respondents were asked to rate the degree to which they experienced each depression-related symptom on a 4-point frequency scale: rarely or none of the times (<1 day); some or a little of the times (1–2 days); occasionally or a moderate amount of time (3–4 days) and most or all of the time (5–7 days) and the possible scores for CES-D ranged from 0 to 60. A continuous overall score between 0 and 60 was produced, with higher scores representing more depressive symptoms. A CES-D score of 16 or higher has previously been considered suggestive of a ‘significant’ level of depressive symptoms in adults.13,17,26,28–30
Generalized anxiety disorderWe used the 7-point Generalised Anxiety Disorder scale (GAD-7), which is designed to assess generalized anxiety (GA) disorder symptoms in adults.34–38 The respondents were asked to rate the degree to which they experienced each GA symptom on a 4-point frequency scale (not at all, several days, over half of the days and nearly every day). The possible scores ranged from 0 to 21, and scores of 5, 10 and 15 represent cut-off points for mild, moderate and severe anxiety disorder symptoms, respectively.34–38 A GAD-7 score of 10 or higher has previously been considered suggestive of a ‘significant’ level of anxiety disorder symptoms in adults.34–38 The GAD-7 scale too was appropriately translated into local languages, and then was back-translated and field-tested to ensure proper readability. We used the GAD-7 scale as it had high sensitivity and good specificity for detecting GA disorder.38
Abuse/mistreatment and neglectHistory of abuse or mistreatment and neglect by friends, family or relatives due to their vision was documented. Neglect was defined as denial of basic needs such as food and shelter. Mistreatment was defined as subjecting patients to verbal abuse, threat of violence, physical beatings or mental abuse. ‘Neglect’ by family and friends and ‘abused/mistreated’ by family were assessed separately. In addition, current difficulty in performing daily tasks as well as requiring help with daily tasks was also documented.
Visual acuityMeasures of visual impairment (VI) were classified into six broad categories as defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10) as mild or no VI (equal to or better than 6/18), moderate VI (worse than 6/18–6/60), severe VI (worse than 6/60–3/60), blindness level-1 (worse than 3/60–1/60 or finger counting at 1 metre), blindness level-2 (worse than 1/60 to light perception) and blindness level-3 (no light perception).39 The baseline visual acuity details were noted from the patient medical records available at the treating hospital.
Statistical analysisMicrosoft Office Excel 2013 and SPSS statistical software (Version 20.0, SPSS Science, Chicago, IL, USA) were used to analyse the data. Descriptive statistics for depression and GA scores are reported for relevant variables, and Chi-square test and one-way ANOVA test were used to assess significance as appropriate.40 The association of depression with GA score is presented separately for men and women patients. We report the prevalence of depression score >16 and GA score >10, among these adults.29,30,34–38 Multiple classification analysis (MCA) was performed to assess the variation in intensity of depression and anxiety with select factors. We used depression and GA scores as continuous variables in MCA, as clinical cutoff scores for these conditions are not readily available for adults in India. For MCA, neglect and mistreated variables were combined into one as they seem not to be fully independent of one another. A similar re-categorization was done for the variables ‘facing difficulty in performing daily tasks’ and ‘need help with daily tasks’; 95% confidence intervals (CI) are reported as appropriate.
RESULTS Participation and demographyA total of 829 adults aged 18 years and above were approached from four tertiary not-for-profit eye hospitals of whom 813 (98.1%) participated. Of the 813 participants, over half were men (56.1%) and three-fourths were aged between 50 and 70 years (74.8%). The median ages were 62 and 60 years for men and women, respectively. About two-thirds were currently married (66.8%). Most participants had no formal education (57.4%), and about one-third were currently not working (36.2%). Over half were currently living with both their children and spouse (59.4%; Table I).
TABLE I.: Baseline demographic, clinical and behavioural characteristics of the patients awaiting cataract surgical services
Variable Categories Total (n=813)A total of 401 (55.1%; men 57.6%, women 51.9%) had moderate VI, followed by those with severe VI (19.2%) and 84 (11.5%) were blind. A significantly higher proportion of women were blind compared to men (45, 14.2%; p=0.042). A significantly higher proportion of men suffered from comorbid ocular conditions than women (426, 52.4%; p=0.01).
Abuse/mistreatment and neglect faced due to visionMen (383, 84%) were significantly more likely to report facing difficulties in performing daily tasks than women because of their vision (284, 79.6%; p=0.02). Similarly, significantly more men (315, 69.1%) reported being neglected by family/friends because of their vision as compared with women (228, 63.9%; p=0.003). A total of 443 (54.5%) adults reported requiring help from others to perform their daily activities, the majority of whom were women (60.8%; p=0.001). The proportion of adults who reported staying at home most of the time due to their vision was higher among women (59.4%) than men (48.5%; p=0.001; Table I).
Distribution of scoresThe overall mean (SD) depression and GA scores were 24.6 (7.8) and 6.3 (4.2) for men and 25.8 (8.9) and 6.9 (4.4) for women, respectively (Table II). Among men awaiting cataract surgery, significantly higher levels of mean depression score were observed among those who reported being neglected or mistreated by their family and friends (28.1, p<0.001), followed by those who were never married (27.7, p<0.032) and those reportedly facing difficulty in performing their daily tasks and required help (27.2, p<0.001). Similarly, the highest levels of mean GA score were also observed among those who reported being neglected or mistreated by their family and friends (7.6, p<0.001) followed by those reportedly facing difficulty in performing their daily tasks and requiring help (7.5, p<0.001) and those with severe VI (7.4, p=0.047). Among women awaiting cataract surgery, the highest levels of mean depression score were among those who reported being neglected or mistreated by their family and friends (30.9, p<0.001), followed by those reportedly facing difficulty in performing their daily tasks and requiring help (28.2, p<0.001) and those with severe VI (28.1, p=0.047). Similarly, the highest levels of mean GA score were observed among those who reported being neglected or mistreated by their family and friends (8.5, p<0.001) followed by those who were 70 years and older (8.4, p=0.001) and those who were blind (8, p=0.044).
TABLE II.: Distribution of depression score with Center for Epidemiologic Studies–Depression29,30 scale and generalized anxiety score with Generalised Anxiety Disorder-734–38 scale by select sociodemographic, clinical and behavioural risk factors among adults awaiting surgical treatment for cataract in India Variable Categories Men Women n=410 Depression score Anxiety score n=318 Depression score Anxiety score Mean SD Mean SD Mean SD Mean SD Age* (years) <50 1 3 19.2 5 . 9 5.2 3.0 2 5 22.4 9 . 3 4.5 3.1 51–69 311 24.9 7.8 6.4 4.1 242 25.7 8 . 8 6.9 4.4 >70 8 6 24.5 8.0 6.0 4.4 5 1 27.8 8 . 7 8.4 4.1 Education† Illiterate 162 26.0 7 . 2 6.6 4.2 245 26.5 8 . 8 7.2 4.3 Primary schooling 122 25.0 7 . 4 6.2 4.1 4 6 24.5 8 . 1 6.5 4.6 Secondary schooling 115 22.6 8 . 2 5.9 4.1 2 5 20.8 9 . 9 5.4 4.1 College or more 1 0 19.5 12.3 4.0 5.4 2 26.5 4 . 9 6.5 2.1 Marital status‡ Never married 9 27.7 9 . 2 5.2 2.6 2 17.5 0 . 7 6.5 2.1 Currently married 318 24.4 8.0 6.3 4.3 173 25.0 9 .0 6.8 4.5 Previously married 8 3 25.1 7 . 2 6.3 3.8 143 26.8 8 . 7 7.1 4.2 Living arrangement§ With children and spouse 277 24.4 8 . 1 6.2 4.3 154 24.5 9 . 2 6.7 4.5 With children without spouse 6 3 25.1 7 . 5 6.3 4.2 9 6 26.6 8 . 5 7.0 4.1 With spouse only 4 0 26.0 5.9 6.8 3.7 2 4 27.0 8.7 6.5 4.2 Living alone 1 9 26.1 8 . 8 7.1 4.4 3 1 27.9 8 . 8 8.0 4.9 With relatives 1 1 20.4 6 . 1 4.6 2.1 1 3 28.1 7 . 3 7.0 2.8 Uncorrected VA Mild or no visual impairment 5 7 22.3 8 . 3 5.6 4.5 4 6 22.0 8 .0 5.5 3.9 (surgery eye)¶ Moderate visual impairment 236 24.6 7 . 2 6.0 3.9 165 25.4 8 . 7 6.9 4.4 Severe visual impairment 7 8 25.8 8 . 1 7.4 4.0 6 2 28.1 9 . 3 7.4 4.6 Blindness 3 9 25.4 9 . 4 6.5 5.1 4 5 28.0 8.9 8.0 4.2 Other ocular Yes 225 25.6 6 . 9 6.6 4.0 152 27.0 7.7 7.3 4.1 conditions** No 185 23.4 8 . 7 5.8 4.3 166 24.7 9 . 8 6.6 4.6 Facing difficulties Facing difficulty and require 185 27.2 7 . 4 7.5 4.3 186 28.2 7.8 7.6 4.3 and require help help with daily tasks†† Facing difficulty but do not 175 23.8 7.0 5.8 3.8 7 9 25.9 7 . 4 7.3 4.1 require help Not facing difficulty but 2 0 18.9 6 . 6 4.3 4.0 1 3 20.2 11.3 4.6 4.7 require help Neither facing difficulty nor 3 0 16.8 7 . 8 2.7 2.8 4 0 16.0 8.2 3.7 3.8 require help Stay home most Yes 194 26.2 7 . 9 7.3 4.3 187 27.1 8 . 8 7.6 4.6 of the times‡‡ No 216 23.1 7 . 6 5.3 3.8 131 23.9 8 . 7 5.9 3.9 Neglected and Yes 229 28.1 7 . 3 7.6 4.2 197 30.9 7 . 2 8.5 3.9 mistreated by No 181 21.9 7 . 2 5.2 3.9 121 22.6 8 . 3 5.9 4.3 family/friends§§The distribution of overall scores for depression and GA was clustered around middle-aged groups of 50–70 years (p=0.001, Fig. 1). However, a bulk of these scores were clustered above and below the clinical cut-off level for depression and GA, respectively.
FIG 1.: Distribution of depression score with Center for Epidemiologic Studies–Depression (CES-D) scale,29,30 (upper) and generalized anxiety scores using the Generalised Anxiety Disorder-7 (GAD-7) scale,34–38 (lower) by age for adults awaiting cataract surgery in India. A CES-D of >16 and GAD-7 score of >10 is considered suggestive of significant levels of depressive and generalized anxiety symptoms29,30,34–38 The horizontal black line depicts the clinical cut-off for depression and anxiety.
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The overall prevalence of depression (CES-D) score of 16 or higher was 87.4% (95% confidence interval [CI] 84.7%–89.6%), and GA (GAD-7) score of 10 or higher was 57.1% (95% CI 53.5%– 60.7%). The prevalence of depression and GA with these scores among men was 88.8% (95% CI 85.3%–91.5%) and 54.9% (95% CI 50%–59.7%), respectively. The prevalence of these in women was 85.5% (95% CI 81.2%–89%) and 60.1% (95% CI 54.5%– 65.3%), respectively.
The prevalence of comorbid depression and anxiety symptoms was 56.6% (95% CI 52.9%–60.2%), which was higher in women, 59.4% (95% CI 53.8%–64.9%) compared to men, 54.4% (95% CI 49.4%–59.3%; p=0.098). The prevalence of depression and anxiety comorbidity was significantly higher in those who reported suffering from ocular comorbid conditions other than cataract, 61.8% (95% CI 56.7%–66.7%; p<0.001, Fig. 2).
FIG 2.: Association between depressive and generalized anxiety symptoms using the Center for Epidemiologic Studies–Depression (CES-D) and Generalised Anxiety Disorder-7 (GAD-7) scales29,30,34–38 among adults awaiting cataract surgery in India * Chi-square test for significance: p=0.098 † Comorbid ocular conditions other than cataract, Chi-square test for signifiance: p<0.001 ‡ Grades of VI measured as per the ICD-10 classification. Chi-square test for signifiance: p<0.109
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Determinants of depression and generalized anxietyTable III shows the MCA for the adjusted predicted mean scores for depression and GA scores. Those reported being neglected and mistreated by family/friends due to their vision, those who were finding it difficult to perform their daily tasks and required help and those suffering from comorbid ocular conditions other than cataract had the highest effect on the intensity of depression with a beta value of 0.352, 0.303 and 0.147, respectively. Correspondingly, being neglected and mistreated by family/friends due to their vision, those who were finding it difficult to perform their daily tasks and required help, and those staying home most of the time due to their vision had the most impact on GA (β 0.219, 0.211 and 0.125), respectively.
TABLE III.: Multiple classification analysis for effect of selected variables on depression and generalized anxiety for adults awaiting cataract surgery in Hyderabad
Variable Categories n=727 Adjusted predicted mean Depression* Generalized anxiety† Mean Beta p Mean Beta p Age (years) <50 3 8 22.5 0.075 0.057 5.1 0.078 0.08 51-69 552 25.2 6.6 >70 137 25.7 6.7 Gender Men 409 24.6 0.075 0.029 6.2 0.085 0.025 Women 318 25.8 7.0 Education Never been to school 407 26.3 0.088 0.084 6.7 0.044 0.683 Primary schooling 168 24.9 6.4 Secondary/senior secondary schooling 140 22.3 6.5 Technical school/college or more 1 2 20.7 5.4 Uncorrected vision in the eye Mild or no visual impairment 102 22.2 0.08 0.096 6.5 0.076 0.197 selected for cataract surgery Moderate visual impairment 401 24.9 6.3 Severe visual impairment 140 26.8 7.0 Blindness 8 4 26.8 7.1 Ocular conditions other than cataract Yes 376 26.2 0.147 <0.001 7.0 0.107 0.003 No 351 2 4 6.1 Facing difficulties and require help Facing difficulty and require help 371 27.7 0.302 <0.001 7.1 0.211 <0.001 with daily tasks Facing difficulty but do not require help 253 24.5 6.6 Not facing difficulty but require help 3 3 19.4 5.2 Neither facing difficulty nor require help 7 0 16.4 4.1 Stay home most of the times Yes 381 26.6 0.032 0.344 7.1 0.125 0.001 No/can't say 346 23.5 6.0 Neglected and mistreated by Yes 425 22.2 0.352 <0.001 5.8 0.219 <0.001 family/friends No 302 29.2 7.7 Full model 727 0.583 <0.001 0.435 <0.001 DISCUSSIONA large proportion of adults awaiting cataract surgical services had significant depressive as well as GA symptoms with over half exhibiting depression–anxiety comorbidity. Men in particular experienced more depressive symptoms, while women had significantly higher GA symptoms.
The study on the burden of mental health disorders across Indian states revealed that the prevalence of depressive and anxiety disorders among the general population was 3.3% each and for both genders combined.41 The prevalence rates of depression in community samples have varied from 1.7 to 74 per thousand population,42,43 and in primary care clinics they are 21%–40.4%.44–47 Studies done in hospitals have shown that 5%–26.7% of cases attending the psychiatric outpatient clinics have depression.48–50 A study from southern India, which assessed depression among the elderly in residential care, found a prevalence of 60% among those with dual visual and hearing impairment.27 As expected, the prevalence of depression and/or GA in our study is manifold higher than reported among general populations in India, indicating that cataract significantly increases the levels of both depressive and GA symptoms in those affected.
Little is known about cataract and its impact on mental disorders among Indian adults. The results of our study build upon prior evidence from other countries of increased psychological vulnerability of adults awaiting cataract surgical treatments.12–16,22,25,28 The major determinants of depression and/or anxiety resulting from untreated cataracts reported in all the earlier studies include poor educational status, gender, reduced quality of life, having comorbid conditions and low visual acuity.12-16,22,25,28 While all these factors appear to be patient-specific, which are more internal in nature, findings from our study reveal the influence of non-patient-specific external risk factors such as being mistreated and neglected by those closest to the subjects such as their family or friends, which had the highest effects on both depression and GA. External risk factors such as family environment and sociocultural interactions in the community need attention and have to be addressed to promote well-being of those with ocular morbidities including those with untreated cataracts. Putting more thrust into awareness, information and education campaigns by the treating eye hospitals towards sensitizing the community to issues surrounding cataract patients and expanding counselling services to include immediate family members as part of the preoperative counselling sessions, be it at the hospital or at the eye screening camps, would go a long way in addressing such external risk factors. It is estimated that by the year 2041, about 16% of India’s population would comprise those who are 60 years or older.51 Not to address such external risk factors by eye healthcare providers would have a direct bearing on the psychological and mental health comorbid conditions among ophthalmological patients.
In our study, the mean scores for both depression and GA were significantly higher for those reportedly facing difficulties and requiring help with daily tasks. Existing scientific evidence suggests that vision loss leads to functional decline which, in turn, impacts the mental health status of the patients.52–55 Conventionally, cataract screenings and identifications in India happened through community eye screening camps,56,57 and since the past decade, through a fixed stand-alone eye clinic called Vision Centres (VC).58 At the eye screening camps or VC, it is often the allied ophthalmic personnel (AOP) such as optometrist, vision technician, camp coordinator or ophthalmic nurse who provide patient counselling services. Many times, these AOP are not trained in counselling patients. Counselling improves the quality of service and builds the confidence of patients, influences the eye health-seeking behaviours and at the same time removes any misinformation, misconceptions surrounding cataracts. Investing in training the existing AOP to provide basic mental health services such as counselling would be a viable option and is recommended as a model for provision of primary eye care services.59 Other studies found that trained lay health worker,60 lay counsellors61,62 and nonspecialist health workers63 can effectively provide basic mental healthcare services in rural areas, which will increase access to psychiatric services. Such low-cost skill transfer-based contextual mental health service delivery model is feasible, acceptable and cost-effective.64 Cataracts are curable and substantially improve the quality of life of patients,4,6,7,9 yet, in many low- and middle-income countries, patients do not have timely access to care, including in India where the cataract surgical coverage rate has been sporadic and is below par at 70%.2 Efforts to reach out to the needy by addressing the barriers and social determinants to the uptake of cataract surgical services are crucial to address cataract-induced VI and associated mental health comorbid conditions. Recruiting and training community health workers (CHWs) and using their services to promote awareness in the communities about cataract surgical services is also an option.65 Active and sustained involvement of CHWs in delivering primary eye care services including generating awareness can translate into increased uptake of cataract surgical services, thereby reducing the burden of cataract and its associated risk factors including mental health stressors.
A little over half of all subjects with cataract had depression and GA and this was significantly manifested in those with comorbid ocular conditions. Although depression and anxiety have historically been seen as distinct conditions, the two disorders are not mutually exclusive and often coexist to varying degrees in the same individual, and patients with comorbid depression and anxiety frequently also have poorer prognosis and require long-term follow-up after treatment.66,67 Our findings have implications for planning psychological services and mental health interventions to improve mental health outcomes among adults awaiting cataract surgery. Eye care service providers do address other ocular comorbid conditions; however, there is a need to train them to look for signs of mental distress and psychological stressors in ophthalmological patients and refer such patients to a qualified mental health practitioner for timely and appropriate management. The state of Kerala has integrated mental health services with general health and this model could be adopted by the eye healthcare service providers to augment referral services to address unmet mental health needs of ophthalmological patients.68
The strength of our study is that it is the largest study to date that has looked at psychological issues among Indian adults awaiting cataract surgical services. The major limitation in our analysis is the non-availability of clinical medical records at some of the partnering hospitals.
ConclusionPsychosocial needs of adults awaiting cataract surgery are often neglected while designing the eye care programme. As most eye care services are provided from stand-alone eye health facilities, there is a need for specific interventions and to build and sustain robust referral mechanisms with qualified mental health practitioners. Training existing eye care service providers (AOP) in the identification of mental health issues and incorporating these into the regular service delivery mechanisms would address this problem to an extent. Investing in patient counselling services and recruiting CHWs to boost awareness locally and to improve uptake of cataract surgical services seems a viable option. Our study has contributed to the evidence and further work is needed to understand the l
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