Gendered Disparities in Quality of Cataract Surgery in a Marginalised Population in Pakistan: The Karachi Marine Fishing Communities Eye and General Health Survey

Background
Marine fishing communities are among the most marginalised and hard-to-reach groups and have been largely neglected in health research. We examined the quality of cataract surgery and its determinants, with an emphasis on gender, in marine fishing communities in Karachi, Pakistan, using multiple indicators of performance.
Methods and Findings
The Karachi Marine Fishing Communities Eye and General Health Survey was a door-to-door, cross-sectional study conducted between March 2009 and April 2010 in fishing communities living on 7 islands and in coastal areas in Keamari, Karachi, located on the Arabian Sea. A population-based sample of 638 adults, aged ≥ 50 years, was studied. A total of 145 eyes (of 97 persons) had undergone cataract surgery in this sample. Cataract surgical outcomes assessed included vision (presenting and best-corrected with a reduced logMAR chart), satisfaction with surgery, astigmatism, and pupil shape. Overall, 65.5% of the operated eyes had some form of visual loss (presenting visual acuity [PVA] < 6/12). 55.2%, 29.0%, and 15.9% of these had good, borderline, and poor visual outcomes based on presenting vision; with best correction, these values were: 68.3 %, 18.6%, and 13.1%, respectively. Of 7 covariates evaluated in the multivariable generalized estimating equations (GEE) analyses, gender was the only significant independent predictor of visual outcome. Women’s eyes were nearly 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. A higher proportion of women’s than men’s eyes had an irregular pupil (26.5% vs. 14.8%) or severe/very severe astigmatism (27.5% vs. 18.2%). However, these differences did not reach statistical significance. Overall, more than one fourth (44/144) of cataract surgeries resulted in dissatisfaction. The only significant predictor of satisfaction was visual outcome (P <0.001).
Conclusions
The quality of cataract surgery in this marginalised population, especially among women, falls well below the WHO recommended standards. Gender disparities, in particular, deserve proactive attention in policy, service delivery, research and evaluation.

研究背景
海洋捕捞社区属于最边缘且难以触达的群体之一，在健康研究中长期被忽视。本研究以性别为重点，采用多项手术性能评估指标，对巴基斯坦卡拉奇市海洋捕捞社区的白内障手术质量及其影响因素进行了探讨。

研究方法与结果
卡拉奇海洋捕捞社区眼部与全身健康调查（Karachi Marine Fishing Communities Eye and General Health Survey）是一项入户横断面研究，于2009年3月至2010年4月期间，在阿拉伯海沿岸卡拉奇凯马里区7个岛屿及沿海区域的捕捞社区中开展。本研究纳入638名年龄≥50岁的成年人作为人群抽样样本。该样本中共有97名受试者（共145只眼）接受过白内障手术。
本次评估的白内障手术结局指标包括视力（使用简化logMAR对数视力表检测的裸眼视力与最佳矫正视力）、手术满意度、散光及瞳孔形态。整体而言，65.5%的手术眼存在不同程度的视力损失（裸眼视力<6/12）。基于裸眼视力评估，其中55.2%、29.0%及15.9%的手术眼分别达到良好、临界与不良视力结局；在最佳矫正视力下，该占比分别为68.3%、18.6%与13.1%。
在多变量广义估计方程（generalized estimating equations, GEE）分析评估的7项协变量中，性别是唯一对视力结局具有显著独立预测作用的因素。在校正家庭经济状况的影响后，女性手术眼出现次优视力结局（裸眼视力<6/18）的概率约为男性的4.38倍（校正比值比为4.38，95%置信区间1.96~9.79；P<0.001）。女性手术眼出现瞳孔不规则（26.5% vs. 14.8%）或重度/极重度散光（27.5% vs. 18.2%）的比例均高于男性，但上述差异未达到统计学显著性。
整体而言，超过四分之一（44/144）的白内障手术患者表示对手术不满意，而手术满意度的唯一显著预测因素为视力结局（P<0.001）。

研究结论
本研究纳入的边缘群体中，白内障手术质量远低于世界卫生组织（World Health Organization, WHO）推荐标准，女性群体的情况尤为突出。尤其需要在政策制定、服务提供、研究与评估环节主动关注性别差异问题。