title: Gendered Disparities in Quality of Cataract Surgery in a Marginalised Population in Pakistan: The Karachi Marine Fishing Communities Eye and General Health Survey.
abstract: 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.
  
  
  
  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).
  
  
  
  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.
authors.affiliation: School of Social Sciences, Faculty of Arts and Social Sciences, The University of New South Wales, Sydney, NSW, Australia; Section of Ophthalmology, Department of Surgery, Aga Khan University, Karachi, Pakistan; Office of Surgical Research, Department of Surgery, Aga Khan University, Karachi, Pakistan.
authors.forename: Khabir
authors.initials: K
authors.lastname: Ahmad
authors.affiliation: School of Social Sciences, Faculty of Arts and Social Sciences, The University of New South Wales, Sydney, NSW, Australia.
authors.forename: Anthony B
authors.initials: AB
authors.lastname: Zwi
authors.affiliation: School of Public Health and Community Medicine, Faculty of Medicine, The University of New South Wales, Sydney, Australia.
authors.forename: Daniel J M
authors.initials: DJ
authors.lastname: Tarantola
authors.affiliation: Isra Postgraduate Institute of Ophthalmology, Al-Ibrahim Eye Hospital, Malir, Karachi, Pakistan.
authors.forename: Abdul Qadeem
authors.initials: AQ
authors.lastname: Soomro
authors.affiliation: Section of Ophthalmology, Department of Surgery, Aga Khan University, Karachi, Pakistan.
authors.forename: Rashid
authors.initials: R
authors.lastname: Baig
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
authors.forename: Syed Iqbal
authors.initials: SI
authors.lastname: Azam
mesh_terms: D001766:Blindness / Q000453:epidemiology / Q000209:etiology*; D002386:Cataract / Q000453:epidemiology*; D002387:Cataract Extraction / Q000009:adverse effects* / Q000592:standards; D003430:Cross-Sectional Studies; D005260:Female; D019538:Health Care Surveys; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D010154:Pakistan / Q000453:epidemiology; D012424:Rural Population; D017678:Sex Distribution; D063507:Sexism; D016896:Treatment Outcome