title: Barriers to uptake of free pediatric cataract surgery in Malawi.
abstract: OBJECTIVE
  To examine the demographic, sociocultural and socioeconomic factors that prevent families of cataract blind children from accepting free pediatric cataract surgery in Malawi.
  
  
  METHODS
  A total 58 parents of 62 children were recruited into the study. Of these, 53 parents partook in in-depth interviews and focus group discussions after the children were screened and the parents offered free cataract surgery. Overall, 37 parents accepted (acceptors) and 16 parents did not accept (non-acceptors) cataract surgery. All interviews were transcribed and iteratively analyzed. Household economic status was quantified using the Progress out of Poverty Index for Malawi.
  
  
  RESULTS
  Acceptors were better off economically (p = 0.13). Understanding of cataract, its causing blindness and impairment, as well as treatment options, by the decision makers in the families was poor. Decision-making involved a complex array of aspects needing consideration before accepting, of which distance to the health facility was a frequently mentioned barrier. Non-acceptors were more likely to come from twice the distance compared to acceptors (p = 0.0098). Non-acceptors were more likely to be peasant (subsistence) farmers than acceptors (p = 0.048). Non-acceptors were more likely to live in a house made of mud bricks with a roof of grass thatch (p = 0.001). There was no significant difference in acceptance rate between educated and non-educated mothers (p = 0.11). Intensive counseling as provided in this project increased the likelihood of accepting surgery.
  
  
  CONCLUSIONS
  Economic hardship and long distances to health facilities decrease acceptance even of free pediatric cataract surgical services, highlighting that just providing surgery free of cost may not be sufficient for the most economically disadvantaged in rural Africa.
authors.affiliation: College of Medicine, University of Malawi , Blantyre , Malawi .
authors.forename: M
authors.initials: M
authors.lastname: Schulze Schwering
authors.forename: Robert P
authors.initials: RP
authors.lastname: Finger
authors.forename: John
authors.initials: J
authors.lastname: Barrows
authors.forename: Michek
authors.initials: M
authors.lastname: Nyrenda
authors.forename: Khumbo
authors.initials: K
authors.lastname: Kalua
mesh_terms: D000293:Adolescent; D002386:Cataract / Q000453:epidemiology*; D002387:Cataract Extraction / Q000191:economics* / Q000706:statistics & numerical data*; D002648:Child; D002675:Child, Preschool; D003466:Cultural Characteristics; D004522:Educational Status; D005249:Fees and Charges; D005260:Female; D017144:Focus Groups; D006302:Health Services Research; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008297:Male; D010290:Parents / Q000523:psychology; D010342:Patient Acceptance of Health Care / Q000523:psychology / Q000706:statistics & numerical data*; D012424:Rural Population / Q000706:statistics & numerical data; D012923:Social Class; D011795:Surveys and Questionnaires; D014786:Vision Disorders / Q000453:epidemiology* / Q000534:rehabilitation
keywords: Africa; cataract surgery; community child health; pediatric cataract; sociocultural barriers