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Examples of interventions to improve access to cataract surgical services against Levesque and colleague’s1 conceptual framework of access to health care (Levesque 2013)
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Figure 1

Examples of interventions to improve access to cataract surgical services against Levesque and colleague’s1 conceptual framework of access to health care (Levesque 2013)

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Logic model
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Figure 2

Logic model

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Study flow diagram
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Figure 3

Study flow diagram

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
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Figure 4

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study
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Figure 5

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Summary of findings for the main comparison. Information video and counselling to improve access to cataract surgical services compared with standard care for cataract

Information video and counselling to improve access to cataract surgical services compared with standard care for cataract

Patient or population: people with vision impairment caused by cataract

Settings: low‐ and middle‐income settings

Intervention: information video and counselling*

Comparison: standard care

Outcomes

Illustrative comparative risks** (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Standard care

Intervention to improve access to cataract surgical services

Change in the prevalence of cataract blindness

Not reported

Prevalence of visual impairment due to cataract

Not reported

Service utilisation: uptake of referral

400 per 1000

407 per 1000 (296 to 527)

OR 1.03 (0.63 to 1.67

434

(1)

⊕⊕⊝⊝

Low1

Service utilisation: uptake of surgery

340 per 1000

364 per 1000 (257 to 487)

OR 1.11 (0.67 to 1.84

434

(1)

⊕⊕⊝⊝

Low1

Cataract Surgical Coverage

Not reported

Surgical outcome (visual acuity in the operated eye)

Not reported

Adverse events

Not reported

*In this study, the intervention group (n = 212) watched a five‐minute informational video on cataract and cataract surgery then received a five‐minute counselling session (based on a script) from a trained nurse in groups of two to three, with family members. The control group (n = 222) were given standard care: they were advised they had decreased vision due to cataract and it could be treated, without being shown the video or receiving counselling.

**The assumed risk was the risk observed in the control group of this study. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; OR: odds ratio

GRADE Working Group grades of evidence
High‐certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate‐certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Low‐certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.
Very low‐certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

1We downgraded by one level for imprecision (wide confidence intervals) and one level for indirectness (study was conducted in rural China and may not be applicable to other settings).

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Summary of findings for the main comparison. Information video and counselling to improve access to cataract surgical services compared with standard care for cataract
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Summary of findings 2. Surgery fee waiver with/without transport provision or reimbursement to improve access to cataract surgical services compared with standard care for cataract

Surgery fee waiver with/without transport provision or reimbursement to improve access to cataract surgical services compared with standard care for cataract

Patient or population: people with vision impairment caused by cataract

Settings: low‐ and middle‐income settings

Intervention: financial incentives and/or reimbursement*

Comparison: standard care

Outcomes

Illustrative comparative risks** (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Standard care

Intervention to improve access to cataract surgical services

Change in the prevalence of cataract blindness

Not reported

Prevalence of visual impairment due to cataract

Not reported

Service utilisation: uptake of referral

Not reported

Service utilisation: uptake of surgery

150 per 1000

291 per 1000 (171 to 497)

RR 1.94 (1.14 to 3.31)

355

(1)

⊕⊕⊝⊝

Low1

Cataract Surgical Coverage

Not reported

Surgical outcome (visual acuity in the operated eye)

Not reported

Adverse events

* In this study, there were three intervention arms and a comparator arm: we have combined the intervention arms to display the results as there were no differences between them.

  • Intervention 1: reminded to use the low‐cost cataract surgery programme at the local hospital and offered free cataract surgery at local hospital (n = 86)

  • Intervention 2: reminded to use the low‐cost cataract surgery programme at the local hospital and offered free cataract surgery at local hospital plus offered reimbursement of transport costs (n = 90)

  • Intervention 3: reminded to use the low‐cost cataract surgery programme at the local hospital and offered free cataract surgery at local hospital plus offered free transport to and from the hospital (n = 93)

  • Comparator: reminded to use the low‐cost cataract surgery programme at the local hospital (n = 86)

**The assumed risk was the risk observed in the control group of this study. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio

GRADE Working Group grades of evidence
High‐certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate‐certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Low‐certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.
Very low‐certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.

1We downgraded by one level for imprecision (wide confidence intervals and statistical analysis not adjusted for cluster randomised design) and one level for indirectness (study was conducted in rural China and may not be applicable to other settings).

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Summary of findings 2. Surgery fee waiver with/without transport provision or reimbursement to improve access to cataract surgical services compared with standard care for cataract
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Table 1. Visual impairment categories (International Classification of Diseases ICD‐10)

Category

Presenting distance visual acuity

Worse than:

Equal to or better than:

0 Mild or no visual impairment

6/18

1 Moderate visual impairment

6/18

6/60

2 Severe visual impairment

6/60

3/60

3 Blindness

3/60

1/60*

4 Blindness

1/60*

light perception

5 Blindness

No light perception

9

Undetermined or unspecified

*or counts fingers (CF) at 1 metre

The term visual impairment comprises categories 1 to 5; blindness comprises categories 3 to 5 (Pascolini 2012).

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Table 1. Visual impairment categories (International Classification of Diseases ICD‐10)
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Table 2. Subgroup analysis hypotheses

Explanatory factors

In which subgroup is the effect hypothesised to be larger

Type of intervention

Uni‐faceted versus multi‐faceted

It is hypothesised that multi‐faceted interventions will have a larger effect than uni‐faceted intentions (Chang 2008).

Targeted versus universal

It is hypothesised that targeted interventions will produce a larger effect for socially disadvantaged groups than universal interventions; universal interventions may benefit socially advantaged groups more than socially disadvantaged groups, and thereby increase inequity (Lorenc 2013).

Supply‐side versus demand‐side

Demand‐side interventions are unlikely to be effective if surgery is not accessible and affordable.

Supply‐side interventions might not be effective if there are unaddressed problems with demand.

Population characteristics

Gender/sex:
female versus male

Women have more barriers and less access to cataract surgical services than men (Lewallen 2009). Lack of social support to seek care is a major barrier for women. It is hypothesised that interventions that aim to modify women’s ability to perceive, to seek or to reach care (Figure 1) will produce larger effects for women than men, while universal interventions may produce larger effects for men.

SES/education/occupation:
low SES/ education/occupation versus higher

People with low SES/education have more barriers and less access to cataract surgical services than people with higher SES/education (Abubakar 2012; Jadoon 2007; Kuper 2008). It is hypothesised that interventions targeted to low‐SES people (especially in relation to ability to pay in Figure 1) would produce larger effects than for high‐SES people, while universal interventions may produce larger effects for high‐SES.

Place of residence:
urban versus rural

As services tend to be located in urban areas, rural dwellers tend to have less access to cataract surgical services than urban dwellers (Abubakar 2012; Jadoon 2007). It is hypothesised that interventions that address barriers faced by rural dwellers (such as those relating to availability and accommodation/ability to reach in Figure 1) would produce larger effects for rural dwellers, while other types of interventions may not produce a difference between urban and rural dwellers.

SES: socioeconomic status

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Table 2. Subgroup analysis hypotheses
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Table 3. Subgroup analyses

Number of people

Odds ratio (95% CI)

Test for interaction (P value)

Outcome: uptake of referral

Place of residence

< 1 hour from hospital

225

0.86 (0.50 to 1.48)

0.49

≥ 1 hour from hospital

209

1.13 (0.65 to 1.95)

Gender

Men

185

0.77 (0.42 to 1.38)

0.35

Women

249

1.11 (0.67 to 1.85)

Education

Received some formal education

196

1.40 (0.80 to 2.47)

0.09

Received no formal education

238

0.71 (0.42 to 1.21)

Socioeconomic status

Patient will self‐pay for surgery

78

1.05 (0.42 to 2.62)

0.81

Patient will not self‐pay for surgery

356

0.93 (0.61 to 1.42)

Higher anticipated loss of income

246

0.89 (0.54 to 1.48)

0.63

Lower anticipated loss of income

167

1.10 (0.57 to 2.13)

More floor space/resident

222

0.78 (0.45 to 1.33)

0.28

Less floor space/resident

212

1.19 (0.69 to 2.05)

Social capital

Family member can accompany to hospital for surgery

369

0.98 (0.65 to 1.49)

0.66

Family member can not accompany to hospital for surgery

65

0.77 (0.29 to 2.09)

Family member accompanied patient to screening

188

0.95 (0.53 to 1.70)

0.77

Family member did not accompany patient to screening

246

1.07 (0.63 to 1.82)

Outcome: uptake of surgery

Place of residence

< 1 hour from hospital

225

0.63 (0.36 to 1.13)

0.10

≥ 1 hour from hospital

209

1.26 (0.71 to 2.22)

Gender

Men

185

0.88 (0.48 to 1.64)

0.94

Women

249

0.85 (0.50 to 1.45)

Education

Received some formal education

196

1.20 (0.67 to 2.15)

0.17

Received no formal education

238

0.68 (0.39 to 1.19)

Socioeconomic status

Patient will self‐pay for surgery

78

0.98 (0.37 to 2.59)

0.80

Patient will not self‐pay for surgery

356

0.85 (0.55 to 1.33)

Higher anticipated loss of income

246

0.85 (0.51 to 1.43)

0.58

Lower anticipated loss of income

167

1.09 (0.54 to 2.23)

More floor space/resident

222

0.79 (0.44 to 1.40)

0.57

Less floor space/resident

212

1.00 (0.57 to 1.75)

Social capital

Family member can accompany to hospital for surgery

369

0.88 (0.57 to 1.36)

0.86

Family member can not accompany to hospital for surgery

65

0.80 (0.28 to 2.30)

Family member accompanied patient to screening

188

1.05 (0.58 to 1.88)

0.64

Family member did not accompany patient to screening

246

0.86 (0.48 to 1.53)

Effect measure: odds ratio; analysis model: fixed effects.
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Table 3. Subgroup analyses
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