Cataract is a major cause of visual impairment and preventable blindness in older people in the world. It is a progressive loss of transparency of the crystalline lens that leads to decreased sharpness of vision, glare, poor contrast sensitivity, and problems with daily activities. Cataract is much more common with age and, therefore, is of particular importance in populations in which there is a high proportion of elderly people. If both eyes are affected, mobility, self-care, reading, taking medications, social interaction, and independence may be impacted(1, 2).

Cataract surgery is one of the most effective and inexpensive surgical procedures for restoring vision. When treatment is available, the surgical techniques used today can lead to a significant improvement in visual function and quality of life. However, the availability of an effective surgery does not always mean that it is being used. Many patients still suffer from surgical cataract in areas of low resources and inadequate health services, where the availability of surgical services is limited, and the patients are unable or unwilling to seek them. The disparity in the need for and use of cataract surgery continues to be a significant public health issue (3, 4).

There are numerous factors that influence whether or not someone decides to have a cataract surgery. At present, some elderly patients with low income or relying on family members may not be able to pay the direct cost of treatment. Other costs, such as transport, investigation, medicines, accommodation and travelling companions can also deter treatment. Access may be also be limited by geographical barriers such as long distance travel and the lack of specialist eye-care services for patients in remote areas (5, 6).

Knowledge and perception also play a key role in treatment uptake. For some seniors, the possibility of effective cataract surgery may be lost to their sight, and for others, they may not realize cataract is treatable at all, or they may think that the loss of vision is an inevitability of their aging. Refusal or delay may be due to fear of pain, surgical complications, postoperative blindness or an unfavorable outcome. There may be additional factors, such as negative experiences with relatives, misunderstandings about surgery, poor counseling and a lack of trust in health care

services, that will impact patient decisions (7, 8).

Patients with bilateral vision loss may find social support especially helpful as their vision loss can become severe enough to make it challenging to travel independently. For elderly patients, it is common that their family members or caregivers need to be present in the hospital with them, help to evaluate them before surgery and support them after surgery. Therefore, in some cases, if the patient is willing to undergo surgery, lack of family support can be a significant practical issue. Waiting times, referral difficulties, the need to travel to a different surgical facility to receive treatment, overcrowding and other healthcare-system issues may create even more barriers (9-11).

Underserved communities are likely to experience several of these barriers simultaneously, yet the relative contribution of economic, social, accessibility-related, and psychological factors may differ according to the local healthcare environment. Identifying the most common barriers is essential for planning interventions that address the reasons patients fail to proceed with cataract surgery. Therefore, the present study was conducted to assess the barriers to cataract surgery uptake among elderly patients with bilateral visual impairment in underserved communities and to determine factors associated with failure to proceed with surgical treatment.

This descriptive cross-sectional study was conducted at Bannu Medical College, Bannu, from April 2025 to October 2025. The study aimed to assess the barriers influencing cataract surgery uptake among elderly patients with bilateral visual impairment living in underserved communities. A total of 85 patients fulfilling the predefined eligibility criteria were enrolled in the study. Participants were recruited from ophthalmology-related clinical services and community-linked referrals using a non-probability consecutive sampling technique. Bilateral cataract surgery patients aged 60 years or older, whose vision loss was considered as a result of cataract, were included. All participants were eligible regardless of their gender. Patients who had a unilateral cataract, had had previous bilateral cataract surgery, had visual impairment primarily from advanced glaucoma, retinal disease, optic nerve disorder or other irreversible eye disease were excluded, as were patients who were not able to provide reliable information due to severe cognitive or communication impairment. A questionnaire was used to gather data, which was a structured interviewer-administered questionnaire that was made according to the aims of the study. Details were gathered on age, gender, educational attainment, family income, previous history of recommendation for cataract surgery, awareness of cataract treatment and willingness to have cataract surgery, area of residence, family or caregiver support and severity and duration of visual impairment. Information regarding clinical and ophthalmological was obtained by patient interview, available medical documents, and routine ophthalmological examination. The barriers to taking up cataract surgery were evaluated under the main domains of financial constraints, transport difficulties, distance to eye care facilities, lack of accompaniment, inadequate knowledge about cataract treatment, fear of surgery, fear of postoperative complications, family discouragement, lack of social support, long waiting time, and previous negative experiences in health care. It was acceptable to indicate multiple barriers. Non-uptake of cataract surgery was defined as not having surgery or made arrangements for it, after being advised or considered for cataract surgery. The objective of the study was explained to each one of the participants and written informed consent was obtained before the data collection. The study ensured the confidentiality of the personal information and was voluntary. The study was carried out following the approval from the pertinent institutional ethical review committee. No invasive procedure was carried out purely for research, and there was no impact to the routine care provided to the patient as a result of the study. Data were analyzed by SPSS version 25.0. Mean and standard deviation were used to summarize continuous variables (age and duration of visual impairment) and frequencies and percentages were used to summarize categorical variables. Association between non-uptake of cataract surgery and selected sociodemographic, socioeconomic, accessibility, awareness and psychosocial factors was evaluated using the chi-square test or Fisher's exact test if appropriate. A p-value of < 0.05 was deemed as statistically significant.

The total number of patients in the study was 85 elderly patients with bilateral cataract. The age of the participants was a mean of 69.8 ± 7.1 years between 60 and 86 years. Most participants were aged 60–69 years (45.9%), followed by those aged 70–79 years (37.6%) and ≥80 years (16.5%). The study population consisted of 52.9% female and 47.1% male. Over half of the respondents had no formal education (56.5%) and 62.4% of respondents were from low monthly income households. 68.2% of the respondents were from rural areas and 31.8% from semi-urban areas.

Table 1. Sociodemographic characteristics of the study participants (n = 85)

Clinical examinations revealed that 38.8% of the subjects had moderate bilateral visual impairment while 44.7% had severe visual impairment and 16.5% had blindness as per the inclusion criteria of the study. The average duration of the visual impairment was 3.6 ± 1.9 years. The most common systemic comorbidity was hypertension, with 44.7% of the participants reporting it, and diabetes mellitus was the second most common, with 29.4% of the participants reporting it. Ocular comorbidities occurred in 20.0% of patients.

Table 2. Clinical and ophthalmological characteristics of participants

Of the 85 participants, 69 (81.2%) were advised to have cataract surgery previously. Only 24 (28.2%) had made arrangements for surgery or had begun surgery, however, 61 (71.8%) did not undergo surgery. 50 participants (58.8%) were aware of the possibility of effective treatment of cataract with surgery. At the time of assessment, 36 patients (42.4%) were willing to have surgery while 49 (57.6%) were unwilling or unsure.

Table 3. Awareness and attitudes regarding cataract surgery

Several obstacles to cataract surgery were mentioned and each individual participant often had more than one reason for postponing or refusing surgery. The most prevalent barrier was financial difficulty (55.3%). 44.7% reported fear of surgery and 40.0% reported transportation difficulties. The respondents reported 37.6% of them being far from an eye-care facility and 35.3% had no family member or caregiver to accompany them. The lack of proper knowledge of cataract treatment was found in 32.9% and 29.4% felt that visual impairment was inevitable a part of ageing.

Table 4. Reported barriers to cataract surgery uptake among study participants

^{Multiple responses were permitted; therefore, percentages do not total 100%.}

The reasons for not going on to cataract surgery were further investigated. Occasional lack of uptake was considerably more common in participants from low-income versus middle and high income groups (81.1% versus 56.3%, respectively, p = 0.016). Patients who were not aware of the surgical treatments for cataract were also more likely not to go on to have cataract surgery (88.6% vs. 60.0%, p = 0.004). Likewise, higher rates of non-uptake (85.3% vs. 62.7%, p = 0.025) were seen in individuals who did not have family or caregiver support. The barriers of transportation and concerns about surgery were also strongly linked to not getting surgery. There was no statistical difference between genders or age group.

Table 5. Factors associated with non-uptake of cataract surgery

Overall, cataract surgery uptake was low despite a high proportion of participants having previously received a recommendation for surgery. Financial constraints emerged as the most frequently reported barrier, followed by fear of surgery, transportation difficulties, long travelling distances, and limited caregiver support. Socioeconomic disadvantage, inadequate awareness, transportation problems, fear of surgery, and absence of family support were significantly associated with failure to proceed with cataract surgery.

Figure 1. Reported barriers to cataract surgery uptake among elderly patients with bilateral visual impairment

(n = 85).

Financial difficulty was the most frequently reported barrier, followed by fear of surgery, transportation difficulties, long distance from eye-care facilities, and lack of an accompanying person or caregiver. Multiple responses were permitted.

The present study assessed barriers affecting cataract surgery uptake among elderly patients with bilateral visual impairment in underserved communities. Despite the availability of effective surgical treatment, a considerable proportion of participants had not proceeded with cataract surgery. More than two-thirds of the study participants had not initiated surgical arrangements, even though most had previously been advised to undergo surgery. This finding indicates that recommendation for surgery alone may not be sufficient to ensure treatment uptake, particularly in communities where socioeconomic limitations, poor accessibility, inadequate awareness, and psychological concerns influence healthcare-seeking behavior (12, 13). More than half of the subjects reported financial difficulty as the most commonly experienced obstacle. This is significant because the elderly in unserviced areas are likely to be economically reliant on relatives, and have little or no fixed income. Surgery costs can go beyond the surgical procedure itself and can include transportation, diagnostic investigations, medications, lodging and the cost of a caregiver to accompany the surgical patient. The result of the present study shows that non-uptake of cataract surgery was significantly higher in participants from the low income households. Thus, the direct and indirect cost savings for cataract treatment can significantly enhance utilization of surgical services in economically disadvantaged populations of elderly people (14, 15). Another significant factor was fear of surgery, a strong determinant for not undergoing cataract surgery. Regardless of medical indication, concerns about pain, surgical complications, loss of remaining vision and unfavorable postoperative outcomes may cause elderly patients to be deterred from undergoing surgery. Such fears may be exacerbated by inadequate knowledge of modern cataract surgery. Furthermore, nearly a third were not well informed about the treatment options for cataract and some considered progressive vision loss to be an inevitable outcome of aging. These perceptions can be responsible for delay to presentation and lower uptake of surgery. Counselling should, therefore, not only focus on the advantages of cataract surgery, but also on the common misconceptions and fears about cataract surgery and its outcomes (16, 17). Geographical and social barriers were also often cited. A significant number of participants reported having transportation difficulties, long distances from an eye-care facility, and not having a person with them. Such difficulties may be significant for older people with bilateral visual impairment as they might not be able to move around on their own and may rely on family members to accompany them to hospital. In the present study, lack of caregiver/family support was significantly associated with surgery non-uptake. This discovery underscores the need to include family members in counselling and to take into account community-based referral systems, transportation support, outreach services and surgical camps in locations where access to specialist eye care services is not readily available (18-20). This interpretation must take into account some limitations of the findings. This study was performed in a single institution with a relatively small population in size, which may reduce generalizability of results to other groups. Data on barriers was predominantly self-reported and could potentially be subject to recall and/or social desirability bias. Moreover, the study had a cross-sectional study design, making it difficult to establish causal relationships between the barriers identified and uptake of cataract surgery. However, the study offers helpful insights into modifiable socioeconomic, accessibility, knowledge-related, and psychological barriers among older adults who have bilateral visual loss. Further studies are suggested to include multi-center studies and community studies to better understand these factors and to determine if targeted financial support, patient counseling, transportation, and community outreach programs increase uptake of cataract surgeries.

Cataract surgery uptake among elderly patients with bilateral visual impairment in underserved communities was limited despite a high proportion having previously been advised to undergo surgery. Financial constraints were the most commonly reported barrier, followed by fear of surgery, transportation difficulties, long distance from eye-care facilities, and lack of caregiver support. Low household income, inadequate awareness, lack of family support, transportation problems, and fear of surgery were significantly associated with failure to proceed with cataract treatment. Improving cataract surgery uptake in underserved populations requires a comprehensive approach that combines affordable surgical services, improved community awareness, effective counselling, transportation assistance, and greater involvement of family and caregivers in the treatment process.

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