Impact of cataract on the livelihood income status of patients availing free cataract surgery in India

INTRODUCTION

Cataract remains one of the leading causes of blindness worldwide, with a significant burden in low- and middle-income countries, including India. According to the World Health Organization (WHO), cataract is responsible for nearly 51% of global blindness, disproportionately affecting those in socioeconomically disadvantaged communities.¹ In India, where a substantial portion of the population relies on daily wage labour and informal employment, the impact of cataract-induced visual impairment on livelihood and income is profound. Vision impairment due to cataract directly affects an individual's ability to perform daily tasks, participate in economic activities, and maintain an independent lifestyle. Studies have shown that visual disability reduces work efficiency, leading to loss of employment, reduction in income, and increased dependency on caregivers. The consequences are particularly severe in India, where a large proportion of the workforce is engaged in manual labour, farming, and small-scale trading all of which require good visual acuity. Cataract, therefore, does not merely impose a medical burden but also a significant socioeconomic challenge.²

Several studies have explored the impact of cataract on quality of life and economic productivity. A landmark study highlighted that untreated cataract leads to decreased productivity and an increased financial burden on families.³ Their research in Latin America and Asia indicated that individuals with cataract-related vision impairment experienced a 30–50% reduction in income levels compared to those with normal vision. This finding underscores the economic importance of timely cataract treatment. In India, a study conducted, evaluated the effectiveness of the National Programme for Control of Blindness (NPCB) and its role in providing free cataract surgeries.⁴ The study reported significant improvements in visual acuity and quality of life post-surgery, but it did not assess the economic rehabilitation of patients. Similarly, another analysed the correlation between visual impairment and employment in rural Indian populations, concluding that cataract surgery significantly improved the chances of returning to work, particularly in agriculture and handicraft sectors.⁵ Another research further reinforced these findings, demonstrating that individuals undergoing cataract surgery were more likely to resume work within six months post-surgery.⁶ Their study, which focused on rural Africa and South Asia, revealed that cataract surgery patients saw a 15–20% increase in income levels. However, the study also noted that economic benefits varied based on age, gender, and nature of employment, suggesting that the broader impact of cataract surgery is influenced by multiple factors. Additionally, studies have assessed the economic burden of blindness in India, emphasising that visual impairment leads to loss of wages and increased household expenditures.^7,8 They argue that cataract surgery is not just a medical intervention but a crucial economic investment for society. However, these studies primarily focus on cost-benefit analyses rather than direct livelihood assessments. More recent studies have adopted a patient-centric approach to understanding the socioeconomic outcomes of cataract surgeries. An investigation examined how free and subsidized cataract surgeries improved household income and overall economic well-being in underserved populations.⁹ Their findings suggested that individuals who regained vision post-surgery were more likely to secure employment, experience improved mental health, and contribute to household income.¹⁰ According to a study by the World Health Organization (WHO), untreated cataract results in a loss of approximately 1% of the global GDP due to decreased productivity and employment.² This study highlights that individuals suffering from cataract lose a significant portion of their income potential, which can be restored through timely surgical intervention. In India, where cataract disproportionately affects the working-age population, free cataract surgeries play a crucial role in economic restoration.

Despite these insights, there remains a lack of region-specific data from India that explicitly connects free cataract surgeries with changes in employment status and income levels. Given India's diverse economic landscape and the variations in accessibility to free surgical programs, a focused study on the impact of such interventions on patients' financial recovery is imperative. Free cataract surgery programs have been implemented across India to mitigate this issue, but their effectiveness in restoring livelihood and economic stability among patients has not been widely examined. While many studies have focused on the clinical outcomes of cataract surgery, there is limited research exploring its impact on economic parameters such as employment status, earning potential, and financial dependency post-surgery. This study aims to bridge this gap by assessing how free cataract surgeries influence the livelihood and income status of beneficiaries in India.

Cataract is not merely a health issue but a socioeconomic challenge, particularly in a developing country like India. While free cataract surgeries have been successful in restoring vision, their true impact on livelihood and income status remains underexplored. By systematically analysing how these surgeries influence economic rehabilitation, this study seeks to provide valuable insights that can inform future policy decisions and improve the implementation of free cataract surgery programs in India. Through this research, policymakers, healthcare providers, and social organisations can gain a deeper understanding of how cataract treatment contributes to socioeconomic empowerment, ultimately fostering a more inclusive and productive society.

METHODS

The study is multicentre, observational, retrospective prospective type and was conducted in 15 locations across India, including Brahmapur, Rayagada, Gaya, Itanagar, Jaipur, Ludhiana, Panvel, Bangalore, Coimbatore, Kanpur, Rishikesh, Chennai, Guwahati, Mandvi, and Nashik. The study period was May 2023 to May 2024. These locations were selected to represent a variety of urban, semi-urban, and rural areas, capturing the diverse socio-economic and cultural contexts in which cataract-related challenges manifest. As inclusion, the study population consisted of patients diagnosed with cataracts and attending hospitals for free cataract surgeries. Patients having an income before their vision was affected by cataracts were interviewed.

A total of 918 participants were included in the study. Adults of varying socio-economic backgrounds were eligible, provided they could communicate effectively to answer the questionnaire. Patients with cognitive impairments or other conditions that interfered with communication were excluded.

A structured questionnaire was developed to gather information on the socio-economic impact of cataract. The questionnaire included sections on demographic characteristics (age, gender, education level, marital status), employment details, income levels, family dependencies, and the duration of vision impairment. Additionally, it covered questions about spectacle use, willingness to return to work post-surgery, and barriers to returning to work. The questionnaire was validated for content relevance and translated into multiple languages to accommodate participants' linguistic needs.

Data collection was carried out by trained field investigators who conducted interviews with patients at the participating hospitals. Investigators were equipped with standardized training in interview techniques, data recording, and ethical considerations to ensure consistency and reliability. Interviews were conducted in a language familiar to the respondents, ensuring clarity and accurate data capture. Participants were informed about the study's purpose, and informed consent was obtained before interviews commenced. The interviews were conducted in hospital outpatient departments during the patients’ pre-surgical evaluations.

Visual acuity measurements for each participant were documented during the interviews based on clinical records. The measurements were classified into four categories: very good (6/6–6/12), good (<6/12–6/18), borderline (<6/18–6/60), and poor (<6/60).

All participants were assured of confidentiality and informed that their participation was voluntary. Personal identifiers were not recorded, and the study adhered to the ethical principles outlined in the Declaration of Helsinki.

The collected data were entered into a standardized database and analysed using statistical software. Descriptive statistics, including frequencies and percentages, were used to summarize demographic and socio-economic variables. Correlations were examined between vision impairment severity, income levels, and employment patterns. The results were compared with findings from existing studies to provide contextual insights and identify trends specific to the Indian population.

RESULTS

A total of 918 patients were included in the study, with 73% (n=668) being male and 27% (n=250) female. The majority of patients belonged to the 51-60 years’ age group (41%), followed by 61-70 years (29%), while the least represented age groups were 30-40 years and 71-80 years, each comprising 4% of the study population. There were no patients above the age of 80 years.

Educational background revealed that nearly half of the patients (45%) were illiterate, while 31% had completed primary schooling and 23% had secondary schooling. Only 1% had attained senior secondary education, with no patients reporting higher education qualifications. In terms of marital status, the majority were currently married (81%), while 16% were widowed, 2% were never married, and 2% were divorced or separated. Regarding the duration of visual impairment, 47% of the patients had been experiencing a decrease in vision for 1-2 years, while 23% had visual impairment for less than six months. A smaller percentage (17%) had symptoms for 6-12 months, and 14% reported vision deterioration for more than two years. Despite experiencing vision problems, only 31% of patients were using spectacles, with the majority (69%) not utilizing any corrective eyewear. Among spectacle users, 34% had been using them for 1-2 years, while 25% had been wearing spectacles for more than three years.

The employment status of the patients indicated that 55% were labourers or daily wage workers, 24% were self-employed or engaged in small businesses, and 14% held private jobs. A significant majority (93%) had been engaged in their current occupation for more than three years. Regarding financial dependency, 36% of patients supported 3-4 family members, while 31% had 1-2 dependents, and 23% were responsible for 5-6 dependents. The impact of vision loss on socio-economic conditions was profound, with 75% of patients reporting that their income had been affected due to cataract-related visual impairment. Before vision deterioration, 38% of patients had a monthly income between ₹5000-₹10,000, and 18% earned more than ₹15,000. However, after vision deterioration, 19% reported having no income, while 36% had an income between ₹1000-₹5000, indicating a significant decline in financial stability. Furthermore, 37% of patients had completely stopped working due to poor vision, and among them, 79% expressed willingness to return to work post-surgery, whereas 21% did not, citing old age (44%), health issues (38%), lack of interest (10%), or family support (8%).

Preoperative visual acuity assessment indicated that 77% of patients had poor vision (<6/60), and 19% had borderline vision (<6/18-6/60). Only a small proportion had good (2%) or very good vision (3%). Regarding the eye to be operated on, 53% of cases involved the right eye, while 47% required surgery on the left eye. The findings highlight the considerable economic and functional burden of cataract-related vision impairment, particularly among labourers and daily wage workers. The study underscores the need for timely cataract interventions to restore vision and improve patients' socioeconomic well-being.

DISCUSSION

The findings of this study highlight the substantial impact of cataract-related visual impairment on the livelihood and economic status of affected individuals. The majority of the patients in this study were male (73%), with a predominant age group of 51-60 years (41%). A significant proportion of patients were illiterate (45%), which could contribute to lower awareness and delayed healthcare-seeking behavior. The study also found that 55% of the patients were labourers or daily wage workers, a group highly susceptible to income loss due to visual impairment. The financial burden of cataracts was evident, as 75% of patients reported income reduction due to vision loss. Before vision deterioration, 38% of the patients earned between ₹5000-₹10,000 per month, but post-impairment, 19% had no income, and 36% earned only ₹1000-₹5000. These statistics underscore the economic vulnerability of cataract patients and the urgent need for timely surgical interventions.

The benefits of cataract surgery extend beyond vision restoration, as 79% of those who had stopped working expressed willingness to return to work post-surgery. This finding aligns with prior research indicating that cataract surgery enhances economic self-sufficiency.¹⁶ However, 21% of patients who opted not to return to work cited reasons such as old age (44%), health issues (38%), lack of interest (10%), or family support (8%). These insights suggest that while cataract surgery improves economic prospects, additional rehabilitation and social support services may be required for certain demographics.

The results of this study are consistent with those of previous research conducted in other low- and middle-income countries. A study reported that 75% of cataract patients experienced improved financial independence post-surgery, similar to the findings of this study.¹⁰ In Ethiopia, found that cataract surgery led to a 60% increase in employment rates among individuals previously unable to work due to vision impairment.¹¹ Additionally, a study reported a substantial reduction in poverty levels among individuals who underwent cataract surgery.¹² The study found that post-surgical patients had a 45% increase in income compared to those who did not undergo the procedure, further reinforcing the economic benefits of cataract intervention. Gender disparities in healthcare-seeking behavior, as observed in this study, are also consistent with findings from other regions. Studies in Africa and South Asia indicate that women are less likely to seek cataract treatment due to social and cultural barriers, necessitating targeted interventions to improve healthcare accessibility for women.¹³ Another crucial aspect observed in this study is the lack of postoperative compliance with spectacle use. Similar findings were reported in studies conducted in Latin America, where patients failed to use corrective eyewear due to affordability concerns or lack of awareness.¹⁴ Addressing these issues through subsidized spectacles and community-based education programs could enhance post-surgical outcomes.

The chi-square value of 68.91 (p<0.05) indicates a highly significant relationship between income levels before and after vision impairment. This confirms that cataract-induced vision loss leads to a considerable decline in earning potential. Similar findings were reported and found that untreated cataracts significantly reduced household income in Bangladesh and Nigeria.¹⁵ The chi-square value of 129.64 (p<0.05) shows a significant correlation between increasing age and declining visual acuity. This supports previous studies indicating that cataract prevalence increases with age.¹⁶ In line with our results, a study in Ethiopia found that age-related vision impairment was one of the leading causes of economic dependency.¹⁷ A chi-square value of 22.53 (p<0.05) indicates that occupation is significantly associated with visual acuity, suggesting that certain occupations are more prone to vision impairment. Labour-intensive workers, particularly those in agriculture and construction, are at a higher risk of cataract-related blindness due to prolonged sun exposure and lack of protective eyewear.¹⁸

Despite the proven benefits of cataract surgery, significant barriers remain that hinder patients from availing of timely treatment. Fear of surgery, lack of awareness, and indirect costs were key concerns raised by patients in this study. Similar concerns have been noted in research from Bangladesh and Nigeria, highlighting the need for large-scale awareness campaigns and financial support mechanisms.¹⁹ Moreover, the long-term socioeconomic impact of cataract surgery warrants further exploration. While short-term income restoration has been well documented, understanding how improved vision influences long-term career growth, education, and financial stability will provide a more comprehensive picture of the intervention’s benefits.

Limitations

Income levels were self-reported, which may have introduced inaccuracies or potential exaggerations. Additionally, pre-surgery income was recalled, increasing the risk of recall bias. Nevertheless, a notable strength of the study is the collection of data from multiple regions across the country, providing a broader and more comprehensive perspective.

CONCLUSION

Cataract remains a major public health issue in India, impacting the livelihood and income status of affected individuals. Free cataract surgery programs have proven to be a cost-effective solution to restoring vision and improving economic productivity. However, further research is needed to assess the long-term socioeconomic benefits of these interventions and identify strategies to enhance their accessibility. Addressing barriers such as lack of awareness, financial constraints, and gender disparities will be crucial in ensuring that cataract surgery reaches all those in need, thereby breaking the cycle of poverty and visual impairment.

ACKNOWLEDGEMENTS

We would like to thank to Mission for Vision's Programme Impact team for their invaluable support and contributions to this work.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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