Self-reported cataracts in older adults in Ghana: sociodemographic and health related factors

Cataract is the leading cause of blindness accounting for nearly 48% of blindness globally [1, 2]. It poses a substantial economic and public health burden especially in developing countries. According to a World Health Organization (WHO) report on global blindness, approximately 90% of global cataract is seen in developing countries and estimates that more than 82% of all blindness occurs in individuals aged 50 and older [2].

In a population based study in Ghana, the prevalence rates of cataract causing low vision or blindness in people aged 40 years and above was 9% in the Volta region [3] and 2% in people aged 30 years and above in the Wenchi area of the Brong Ahafo region [4], two of the ten regions in Ghana. The burden of cataracts is not limited to financial costs to society alone, older persons living with un-operated cataracts are likely to have significantly reduced quality of life due to low vision. Other co-morbid conditions in older persons further reduces their quality of life. Decreases in functional abilities may be attributed to other age-related processes but may actually be associated with the onset of cataract.

Some health, lifestyle and environmental conditions have been associated with the development of cataracts. Research has strongly associated diabetes, smoking and ultra violet light exposure with the development of age related cataract [5–9]. Other factors inconclusively implicated in the development of cataracts include body mass index [10, 11] and post menopausal decline in estrogen [12].

Aging is often accompanied by the cumulative impact of chronic disease, increased prevalence of disability, worsening health status and reduced quality of life among the growing number of older persons. Aging, in itself, has been associated with a decline in visual functioning, with associated decline in physical and mental functioning. A number of studies have demonstrated impact of cataract related visual impairment on quality of life [13, 14]. These studies, showed that worsening of general functioning, psychosocial and overall eyesight were associated with increased visual loss. Those with increased visual loss were more likely to report dissatisfaction with quality of life and had poorer self-rated health than persons with normal vision.

In addition, smoking, body-mass index, and exercise patterns in midlife and late adulthood have been suggested as predictors of disability in later years. For the average person, efforts to reduce modifiable health risks may result in a postponement of initial disability and decreased lifetime disability [15].

Current eye health services in Ghana are organized at three levels, national, regional and district [16]. The national and regional levels provide specialized eye care services through the teaching and regional hospitals. Basic eye health services at the district is provided through district hospitals by ophthalmic nurses (i.e. state registered general nurses who have additional training in ophthalmology). Unlike the general health delivery system with structures to provide health care at sub-district and community level [16], eye health services is limited to the district level. Sub-districts and communities (where most of the rural population reside) receive eye care services through outreach programmes and special mobile eye clinics.

The goal of this analysis is to describe the sociodemographic, health related factors and life satisfaction index in older adults with self-reported cataract in Ghana. It is aimed at providing guidance for national plans on eye care for older persons and to contribute to national policy on interventions to mitigate health related factors in the older adult population.

SAGE Wave 1 was undertaken in Ghana in a partnership between the University of Ghana’s Department of Community Health, the Ministry of Health and WHO, as part of a multi-country longitudinal study to complement existing aging data sources and to inform policy and programmes [17, 18]. A nationally representative sample of respondents ≥ 50 years were interviewed on socio-demographic background, health risk factors, chronic conditions, well-being and health insurance coverage. Face-to-face interviews and data entry were undertaken between May 2007 and June 2008. Ethical approval for SAGE Wave 1 in Ghana was given by WHO’s Ethical Review Board and the University of Ghana Medical School Ethics and Protocol Review Committee. All study participants provided informed consent [17, 18].

Analysis of satisfaction with daily living among older adults found the highest prevalence of cataract among those who expressed dissatisfaction with life (9.9%) and the lowest prevalence (4.7%) among those satisfied with life.

Cataract is one of the major conditions chosen by the global initiative, Vision 2020—The Right to Sight, due to the magnitude of its contribution to the burden of blindness [22]. Several studies which focused on the burden of visual loss from cataracts demonstrate the prevalence of cataracts increases with increasing age and is slightly higher among women [23–25]. Our study confirms the findings from these studies.

An appreciation of the impact of visual impairment or blindness on one’s functional ability and quality of life is useful in providing a comprehensive picture of the burden of visual impairment beyond clinical evaluation [26]. In addition, other non-communicable and chronic diseases currently accounting for 60% of deaths globally per annum and 47% of the global burden of disease [27] are mostly associated with aging. The frequency of these conditions increases with age, and they do occur concurrently with cataract as shown in this and other studies [28, 29].

Prevalence of cataract among older persons was determined through a question on whether they have been told by a health professional that they have cataract. In the health delivery system of Ghana, these health professional are either doctors or ophthalmic nurses with capacity to diagnose basic eye conditions including cataracts [16]. The observation suggests that those diagnosed might have accessed eye care services at health facilities or during screening programs. Thus increased prevalence may imply improved access to health care and not necessarily increased disease burden. The prevalence of cataract in this group of people (5.4%) is lower than that reported in the cataract prevalence study among those 40 years and older in the Volta region, one of the ten regions in Ghana (9%) [3]. These differences may be as a result of the differences in the study design, the earlier studies were based on population screening and limited to cataract causing low vision or blindness. In this analysis most cases of cataracts (of any degree of maturity), were more likely to have been diagnosed by trained health professionals at the health facility; hence the relatively higher prevalence in the earlier studies.

Urban residents reported statistically significant higher rates (6.6%) than rural residents (4.4%). This may be related to better access to eye health care with aggregation of eye care services in urban areas in Ghana. Rural areas have limited access and residents depend mainly on erratic outreach services for eye health care. Most rural residents access health care at sub-district levels (health centres and community-based health care) where routine eye care services are unavailable. In addition overall cataract surgical uptake among older persons in Ghana from the national report on SAGE wave 1 was 48.9% [17]. Access to eye care services is critical for early risk detection and prevention of blindness or visual impairment. Well structured outreach eye care services for rural residents or inclusion of basic eye health services at sub-district levels is critical to improve eye health of older persons in Ghana.

Older adults living without a partner (separated/divorced/ widowed) reported significant higher prevalence of cataract (6.6%), compared to those with a partner (married/cohabiting) (4.3%). It may imply this group of older persons might have assessed health care previously and been diagnosed or that older persons living alone are less likely to access health care services; thus the relative higher prevalence of cataract. This may be related to other social support factors; the older adult with visual disability may have multiple disabilities as well [29]. These older adult would need more assistance (physical, social and economic) to access eye care services and living alone may limit the availability of this assistance.

Persons with higher education, higher income and health insurance reported significant higher prevalence of cataract. A potential explanation is their ability to access eye care services due to better knowledge on availability of these services, ability to afford other personal costs involved in seeking health care and improved financial access to health care through the national health insurance scheme. Older adults with low educational background on the other hand may not attach much importance to seeking early and appropriate eye care services. The fifth round of the Ghana living standards survey report in 2008 showed that 31% of all adults had never been to school, less than one-fifth (17%) attended school but did not obtain any qualifications; while a small percentage of 14% possessed secondary or higher qualification [30]. Improving the literacy level of Ghanaians is likely to encourage self-reporting to medical facilities for early diagnosis and treatment.

Generally, in this analysis, older persons in low income groups, poorly educated or living alone had some difficulty seeking vision services and care to prevent blindness or visual impairment. This constitute a vulnerable group who may require special attention to access eye care services. Social protection strategies including enrolment of older adults freely on the national health insurance scheme (NHIS) should be a national health policy worth considering. Currently only older persons ≥ 70 years are eligible for free enrolment on the NHIS [31].

Analysis also demonstrated that prevalence of self-reported cataract was relatively higher in older persons with health related factors such as obesity, diabetes, hypertension, previous history of stroke and alcohol use. Prevalence of cataract in persons with obesity, diabetes, hypertension, previous history of stroke were 5.1%, 8.4%, 10.4% and 11.4% respectively. Among older persons who had ever used alcohol or tobacco, the prevalence was 5.7% and 4.9% respectively. These findings agree with those in other studies that found similar associations [23, 24]. An interesting observation however, was that older persons who had used tobacco had relatively lower prevalence of self-reported cataract. The authors suggest a more detailed study to determine possible factors that may account for this.

A public health approach on behavioural modification (for modifiable and preventable risks- obesity, alcohol consumption and tobacco use) may be required to improve the eye health of older persons in Ghana. Diabetes is recognized as a significant risk factor due to it metabolic effect on the crystalline lens [32, 33]; disease specific health prevention efforts at national and local levels is imperative.

Analysis on satisfaction with daily living among older persons indicate prevalence of cataract is highest among the few older persons who expressed dissatisfaction with life (9.9%) and is lowest (4.7%) among those satisfied with life. Studies among older persons in communities, identified hearing and visual impairments as important factors that lead to functional decline and increased morbidity (imbalance, hip fracture, and depression) as well as mortality [29]. In addition, visual loss in older adults poses significant challenges for families who have to support them; existence of such social support for older persons in communities is often lacking [29].

In Bangladesh, Polack and others in 2008 [27] found that cataract related visual impairment negatively affected perceived health and well-being, beyond vision-specific experience. Also worsening general functioning, psychosocial and overall eyesight scores were found to be associated with increased visual loss. In their study, those with self-reported cataract significantly reported more problems with mobility, self-care, activities of daily living, pain and depression/anxiety and had significantly poorer mean self-rated health. Influence of cataract on the health and social wellbeing of individuals have also been demonstrated in studies from Kenya [14] and India [13].

Prevalence of cataract increased significantly with increasing age, was slightly higher among women, urban residents and older adults living without a partner. Significantly higher prevalence of self-reported cataract were observed in older persons with higher education, higher income and health insurance (due probably to better access to eye health care). Those who were poorly educated and with low incomes had some difficulty seeking vision services and care to prevent blindness or visual impairment.

Risk modification through effective primary prevention and health promotion efforts; behavioural modification, including public health campaigns are key efforts to limit the burden of cataract among older persons in Ghana. Well structured national outreach eye care services for rural residents and inclusion of basic eye health services at sub-district health levels of Ghana's primary health care structure are needed. Increased family support and national social protection strategies (including enrolment of older adults on national health insurance scheme) linked to the national aging policy will improve access to eye health care.

Yawson AE , Mensah G, MinicuciN and Biritwum RB are members of the WHO Multi-country SAGE Team who conducted the SAGE Survey in Ghana. Naidoo N, Chatterji S and Kowal P are members of the WHO Multi-country SAGE Team and coordinators of the multi-country study at the WHO Headquarters in Geneva. EM Ackuaku-Dogbe is a Consultant Ophthalmologist of the University of Ghana Medical School and NA Hagan Seneadza is a Specialist Public Health Physician of the Korle-Bu Teaching Hospital.