title: Factors affecting cataract surgical coverage and outcomes: a retrospective cross-sectional study of eye health systems in sub-Saharan Africa.
abstract: BACKGROUND
  Recently there has been a great deal of new population based evidence on visual impairment generated in sub-Saharan Africa (SSA), thanks to the Rapid Assessment of Avoidable Blindness (RAAB) survey methodology. The survey provides information on the magnitude and causes of visual impairment for planning services and measuring their impact on eye health in administrative "districts" of 0.5-5 million people. The survey results describing the quantity and quality of cataract surgeries vary widely between study sites, often with no obvious explanation. The purpose of this study was to examine health system characteristics that may be associated with cataract surgical coverage and outcomes in SSA in order to better understand the determinants of reducing the burden of avoidable blindness due to cataract.
  
  
  METHODS
  This was a descriptive study using secondary and primary data. The outcome variables were collected from existing surveys. Data on potential district level predictor variables were collected through a semi-structured tool using routine data and key informants where appropriate. Once collected the data were coded and analysed using statistical methods including t-tests, ANOVA and the Kruskal-Wallis analysis of variance test.
  
  
  RESULTS
  Higher cataract surgical coverage was positively associated with having at least one fixed surgical facility in the area; availability of a dedicated operating theatre; the number of surgeons per million population; and having an eye department manager in the facility. Variables that were associated with better outcomes included having biometry and having an eye department manager in the facility.
  
  
  CONCLUSIONS
  There are a number of health system factors at the district level that seem to be associated with both cataract surgical coverage and post-operative visual acuity outcomes. This study highlights the needs for better indicators and tools by which to measure and monitor the performance of eye health systems at the district level. It is unlikely that epidemiological data alone is sufficient for planning eye health services within a district and health managers and study coordinators need to consider collecting supplementary information in order to ensure appropriate planning can take place.
authors.affiliation: Kilimanjaro Centre for Community Ophthalmology International, Division of Ophthalmology, University of Cape Town, Cape Town, South Africa. slewallen@kcco.net.
authors.forename: Susan
authors.initials: S
authors.lastname: Lewallen
authors.affiliation: Sightsavers, 35 Perrymount Road, Haywards Heath, RH16 3BW, West Sussex, UK. eschmidt@sightsavers.org.
authors.forename: Elena
authors.initials: E
authors.lastname: Schmidt
authors.affiliation: Sightsavers, 35 Perrymount Road, Haywards Heath, RH16 3BW, West Sussex, UK. ejolley@sightsavers.org.
authors.forename: Emma
authors.initials: E
authors.lastname: Jolley
authors.affiliation: International Centre for Eye Health, London School of Hygiene and Tropical Medicine (LSHTM), London, UK. robert.lindfield@lshtm.ac.uk.
authors.forename: Robert
authors.initials: R
authors.lastname: Lindfield
authors.affiliation: Bristol Eye Hospital, Bristol, UK. whd1_uk@hotmail.com.
authors.forename: William H
authors.initials: WH
authors.lastname: Dean
authors.affiliation: Division of Ophthalmology, University of Cape Town, Cape Town, South Africa. colin.cook@uct.ac.za.
authors.forename: Colin
authors.initials: C
authors.lastname: Cook
authors.affiliation: Rwanda International Institute of Ophthalmology and Dr Agarwal's Eye Hospital, Kigali, Rwanda. ciku@email.com.
authors.forename: Wanjiku
authors.initials: W
authors.lastname: Mathenge
authors.affiliation: Kilimanjaro Centre for Community Ophthalmology International, Division of Ophthalmology, University of Cape Town, Cape Town, South Africa. pcourtright@kcco.net.
authors.forename: Paul
authors.initials: P
authors.lastname: Courtright
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D002386:Cataract / Q000453:epidemiology*; D002387:Cataract Extraction / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data; D006801:Humans; D015995:Prevalence; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D014792:Visual Acuity / Q000502:physiology