Ophthalmic Epidemiology, 15:372382

ISSN: 0928-6586 print / 1744-5086 online

DOI: 10.1080/09286580802478716

The Impact of Cataract on Time-use: Results from a

Population Based Case-Control Study in Kenya, the
Philippines and Bangladesh
Sarah Polack,1 Hannah Kuper,1 Cristina Eusebio,2 Wanjiku Mathenge,1,3 Zakia Wadud,4 and Allen Foster1
1 London School of Hygiene and Tropical Medicine, London, United Kingdom
2 Cataract Foundation of the Philippines, Bacolod, Philippines
3 Rift Valley Provincial Hospital, Nakuru, Kenya
4 Child Sight Foundation, Dhaka, Bangladesh

ABSTRACT
Purpose: Cataract is the leading cause of blindness in the world, and is particularly common
in low-income countries. Cataract is asserted to increase poverty through reduced productiv-
ity; however there is a lack of empirical data supporting this claim. The aim of this study was
to examine the relationship between visual impairment from cataract with time-use in adults
(aged 50 years) in Kenya, Bangladesh, and The Philippines. Methods: A population-based
case-control study was conducted in three countries. Detailed time-use data were collected
through interview from 139, 216 and 238 cases with visually impairing cataract and 124, 280
and 163 controls with normal vision in Kenya, Bangladesh and Philippines, respectively during
20052006. Results: Cases were substantially less likely than controls to participate in pro-
ductive activities, including paid work and non-market activities (odds ratio [OR] across three
countries is 0.2 95% confidence interval (CI): 0.10.3) and in leisure outside of the household
(OR 0.7, 95% CI: 0.5, 0.9). Among cases, those with more severe visual impairment spent sig-
nificantly less time on productive activities and leisure outside of the home, and more time on
no particular activity (Kenya and Bangladesh) or leisure in the home (The Philippines). Cases
were substantially more likely to require assistance in any activity than controls in Kenya (OR
9.8, 95% CI: 3.3, 29.8), Bangladesh (OR 8.6, 95% CI: 5.114.4) and the Philippines (OR 2.7, 95%
CI: 1.45.1). Conclusions: Cataract visual impairment restricts engagement in productive and
leisure activities in this population of older adults in three different low income settings.

INTRODUCTION
Cataract is the leading cause of blindness worldwide,1 and
is particularly common in low-income countries where access
to surgery remains low.2 Cataract is largely confined to people
aged above 50 years, and as populations continue to grow and
age, this burden is likely to increase.
Received 21 December 2007; accepted 2 September 2008.
Keywords: Cataract; visual impairment; time-use; daily activities;
low-income countries
The rights in a contribution prepared by an employee of the UK
government department, agency, or other Crown body belong to
the Crown and are not subject to United States copyright law.
Correspondence to:
Sarah Polack
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT, UK
email: sarah.polack@lshtm.ac.uk
People with cataract have poorer quality of life and increased
difficulties with activities of daily living.38 Cataract is also
asserted to have economic implications through reduced pro-
ductivity of the visually impaired person as well as opportunity
costs to household members who look after them.911 Estimates
of this economic impact of cataract have been based on assump-
tions of likely productivity losses.911 However, there is little
empirical data on the relationship between cataract visual im-
pairment and allocation of time to different activities, 12,13 and
no data on detailed time-use.
Time-use studies present an important opportunity to ex-
plore this relationship. They provide comprehensive data on
participation and time spent on different activities, includ-
ing productive activities (e.g., paid work, domestic and other
non-market) and may therefore provide supportive evidence
of the economic impact of cataract. Studies in high income
settings suggest engagement in activities contributes to well-
being among older adults.14 Time-use information can therefore
provide additional insight into the direct and indirect impacts

372 NovemberDecember 2008 Ophthalmic Epidemiology

of cataract both from a personal well-being and economic
perspective.15
In this multi-center population based case-control study
we explore whether visual impairment from cataract affects
time-use in people aged 50 in two low income (Kenya and
Bangladesh) and one lower-middle income (The Philippines)
setting.
METHODS
Study sample
The four study sites were Nakuru district (Kenya), Satkhira
district (Bangladesh) and Negros Island and Antique district
(the Philippines) (Figure 1). All study areas were predominantly
rural. Data collection took place during 200506.
In each country, cases and controls were identified through
a population-based survey of blindness.16 Clusters were iden-
tified using systematic sampling with probability proportionate
to size and households within clusters were selected using com-
pact segment sampling.17 All subjects in each cluster underwent
a visual acuity (VA) test using a Snellen tumbling E chart and
ophthalmic examination by an ophthalmologist using a torch
and direct ophthalmoscope in a shaded area. The following cat-
egories of presenting VA were used:
6/66/18 Normal vision (controls only)
<6/246/60 Moderate visual impairment (MVI)
<6/603/60 Severe visual impairment (SVI)
<3/60>PL Blind
PL Perception of light only
Cases were defined as aged 50 years resident in the sur-
vey area, with best corrected VA<6/24 in the better eye from
cataract. Due to logistical and time constraints, additional cases
were identified in each setting through community-based case
detection, using the same cluster sampling procedure, exami-
nation and case definition. For each case, one or two age- sex-
cluster- matched controls were randomly selected from partic-
ipants in the survey who were aged 50 years, with VA6/18
in the better eye and were residents of the survey district. Cases
and controls who were not able to communicate (e.g., deafness,
dementia) were excluded.
Recording of time-use
Time-use data were collected using the stylized activity list
developed for the Living Standards Measurement Survey.15 This
questionnaire contains a pre-set list of common daily activi-
ties (personal, household, paid work, work for own use, leisure,
no activity). Participants were asked whether they had been in-
volved in each activity in the last week and yesterday. If they
had been involved in an activity yesterday they were asked
to estimate how much time they had spent on the activity and
whether they received any assistance. Interviewers checked that
total time reported was close to 24 hours and if not went through
the list again with the respondent until the total was between 22
Ophthalmic Epidemiology
and 26 hours. In summary, this method generates three different
data for analysis:
1. Participation: whether or not subjects had participated
in each different activity in the previous week (binary
variable)
2. Time: the amount of time spent on different activities the
previous day (continuous variable)
3. Assistance: whether or not subjects had assistance with
different activities (binary variable).
Activity classification
Activities were grouped as follows:
Personal: Sleep, bathing, dressing, eating, other
Household domestic: Cooking/washing dishes, cleaning
house/clothes, shopping, looking after children/elderly/sick,
other
Paid work: paid employment, commission work, self em-
ployed/own business, other paid work
Work for own use: Agriculture, animal rearing, fetching fire-
wood/water, processing agricultural products/food, other
Leisure outside home: social visits*, attending ceremonies*,
attending meetings.
Leisure inside home: reading/listening to radio/watching
TV; chatting, relaxing with friends/family*; prayer* (in
Bangladesh), other.
No activity*
Travel (any purpose) (Activities marked * were added to the
original version of the questionnaire based on pilot testing.)
Productive activities refers to engagement in one or more
of household/domestic work, paid work and work for own use.
Mean proportion of time spent on each activity group yester-
day was calculated by dividing total minutes on specific activ-
ity group by the sum of minutes reported on all activities for
that individual. All eligible respondents were included whether
or not they had participated in that activity. The proportion of
participants receiving assistance for an activity was assessed re-
gardless of whether or not they did the activity. Respondents
were excluded from the analysis of proportion of time spent if
total time was <19 hours or >29 hours.
Questionnaires were translated into local languages for each
country and back translated into English. Differences in the
translated and original English version and appropriateness of
the language for the target population were discussed and mod-
ified accordingly. Interviews were conducted by trained inter-
viewers and regularly observed by supervisors. Ophthalmic ex-
amination and interviews were conducted in respondents own
homes.
Recording of covariates
Data were collected on standard socio-demographic indica-
tors. Self-rated health status was assessed by asking respondents
to rate their overall health state today on a scale of 0 (worst
imaginable health) to 100 (best imaginable health). Information
was collected about household ownership of assets and building
NovemberDecember 2008 373
materials of the house, and this was used to create a socio-
economic-status (SES) index for each household using Principle
Components Analysis, separately for each country.18 The SES
index was divided into quartiles.
Study design
In summary, for each of the three countries, one group of
cases (clinical lens opacity associated with visual acuity loss)
and one group of controls (with normal vision) were identified.
Cases were subdivided into four visual acuity level subgroups.
All cases and controls were interviewed about their involvement
in different activities in the previous week and previous day and
whether or not they had assistance. The subject also indicated
the absolute amount of time spent on each activity the previous
day and was assisted to ensure the total time on activities added
up to 24 hours. The proportion of time spent on each category
of activities was then calculated.
Statistical analysis
Time-use and assistance by case/control status
Multivariate logistic regression analyses were conducted to
compare participation in different activity groups by case/control
status adjusted for the matching variables (age and gender). The
association between case/control status and proportion of time
spent on different activity groups was described using means
and 95% confidence intervals. Analyses of variance were also
performed to assess the relationship with adjustment for the
matching variables (age and gender).
Time-use by level of VA in cases
To assess participation in activities by level of VA among
cases, odds ratios and 95% confidence intervals were derived
from logistic regression analyses using the MVI category as the
reference value. The association between level of visual impair-
ment in cases and mean proportion of time spent the previous
day was described using means and 95% confidence intervals.
Ethical considerations
Informed signed/thumb-printed consent was obtained from
all study participants. Cases were offered free cataract surgery.
People with visual impairment who were not eligible to be study
cases were referred for treatment. Ethical approval was granted
by the London School of Hygiene and Tropical Medicine,
Kenya Medical Research Institute, Bangladesh Medical Re-
search Council and the University of St. La Salle, Bacolod, The
Philippines.
RESULTS
Study population
This study included 139 cases and 124 controls in Kenya,
217 cases and 280 controls in Bangladesh, 238 cases and 163
controls from the Philippines (two sites combined). The majority
374 NovemberDecember 2008 Ophthalmic Epidemiology
of cases were identified through the survey, rather than through
case detection (Table 1).
Baseline characteristics
Cases and controls were matched reasonably closely by gen-
der, but cases were over-represented in the older age groups
compared to controls (Table 1). In all countries, cases were
older, were less likely to have a job and had substantially worse
self-rated health than controls. In each country cases were over-
represented in the poorer SES group. In Kenya and Bangladesh
cases were also less likely to be literate or have had formal edu-
cation, although there was no association with these variables in
the Philippines. In Bangladesh and the Philippines the majority
of cases were blind (55% and 56%, respectively) and a smaller
proportion were SVI (19% and 18%) or MVI (26% and 26%),
while in Kenya fewer were blind (39%) and a larger proportion
had MVI (39%).
Participation in activities in the last week in
cases and controls
Patterns of participation in activities were broadly similar
in the three countries (Table 2). In each country, after adjust-
ment for covariates, cases were substantially less likely to be
involved in productive activities compared to controls (odds ra-
tio (OR) for three countries combined is 0.2, 95% confidence
interval (CI) 0.10.3). Cases were also less likely to be involved
in leisure outside the home compared to controls in Kenya and
the Philippines, while in Bangladesh there was no difference
(OR for three countries combined is 0.7, 95% CI: 0.5, 0.9). In
each country there was no difference between cases and con-
trols in participation in leisure in the home and no particular
activity.
Participation in activities in the last week by
level of visual acuity
Among cases, participation in household domestic activities
and work for own use decreased with worsening VA after ad-
justment for covariates, and this pattern was observed in each
country (Table 3). The trend was driven largely by the reduction
in these activities among those who were blind or PL. Across the
three countries, cases with MVI were more likely to be involved
in household work (77%) or work for own use (66%) compared
to cases with PL (37% and 18%, respectively).
In Bangladesh and Philippines, participation in paid work
also decreased with worsening VA, while this could not be ana-
lyzed for Kenya as the number of people in paid work was too
small. In Kenya and Bangladesh people with poorer VA were
less likely to engage in leisure activities outside the home (43%
and 39% in cases with MVI compared to 10% and 24% in cases
with PL in Kenya and Bangladesh respectively), while this trend
was not apparent in the Philippines. Engagement in no activ-
ity in the past week was not associated with VA in Kenya and
Bangladesh, while among cases in the Philippines no activity
was associated with poorer VA.
 Table 1. Characteristics of the study sample

Kenya Bangladesh The Philippines

Cases (%) Controls Age & gender Cases (%) Controls Age & gender Cases (%) Controls Age & gender
n = 139 (%) adjusted OR n = 217 (%) adjusted OR n = 238 (%) adjusted OR
(69*) n = 124 (95% CI) (55*) n = 280 (95% CI) (93*) n = 163 (95% CI)
Age
5059 4% 9% 1.0** 9% 14% 1.0** 9% 14% 1.0**
6069 12% 23% 1.3 (0.44.4) 24% 36% 1.0 (0.51.9) 24% 28% 1.3 (0.62.6)
7079 35% 40% 2.1 (0.76.6) 43% 41% 1.6 (0.93.0) 41% 47% 1.2 (0.62.4)
80 50% 27% 4.5 (1.413.9) 24% 9% 4.6 (2.29.7) 26% 12% 3.1 (1.46.9)
Gender
Male 40% 40% 1.0** 41% 44% 1.0** 36% 45% 1.0**
Female 60% 60% 1.0 (0.61.7) 59% 56% 1.4 (0.92.1) 64% 55% 1.3 (0.82.0)
Education
None 76% 60% 1.0 84% 64% 1.0 11% 10% 1.0
Some 24% 40% 0.5 (0.30.9) 16% 36% 0.3 (0.20.5) 89% 90% 0.9 (0.51.9)
Literacy
Cant read 76% 52% 1.0 91% 70% 1.0 18% 15% 1.0
Can read 24% 48% 0.3 (0.20.6) 9% 30% 0.2 (0.10.3) 82% 85% 0.9 (0.51.5)
Job other than own field
No 99% 92% 1.0 96% 83% 1.0 94% 84% 1.0
Yes 1% 8% 0.1 (0.010.6) 4% 17% 0.3 (0.10.6) 6% 16% 0.4 (0.20.8)
Socio-economic status
1 (poorest) 37% 18% 1.0 31% 22% 1.0 27% 23% 1.0
2 29% 22% 0.7 (0.31.5) 27% 23% 0.8 (0.51.4) 28% 25% 0.9 (0.51.6)
3 19% 28% 0.4 (0.20.8) 24% 26% 0.6 (0.41.0) 25% 25% 0.8 (0.51.5)
4 (least poor) 16% 32% 0.3 (0.10.6) 18% 29% 0.4 (0.20.7) 20% 28% 0.5 (0.30.9)
Visual acuity
6/18(controls) 0% 100% 0% 100% 0% 100%
<6/246/60 39% 0% 26% 0% 26% 0%
<6/603/60 22% 0% 19% 0% 18% 0%
<3/60 >PL 17% 0% 14% 0% 31% 0%
PL 22% 0% 41% 0% 25% 0%
Self-rated health (tertiles)
Poor 70% 46% 1.0 49% 23% 1.0 62% 32% 1.0
Middle 15% 14% 0.7 (0.41.6) 36% 48% 0.4 (0.20.6) 20% 21% 0.5 (0.30.9)
Good 15% 40% 0.3 (0.20.6) 16% 29% 0.3 (0.20.5) 18% 47% 0.2 (0.10.4)

OR = Odds ratio; CI = Confidence interval; PL = Perception of light.

*Number of cases identified from community based case detection.
**Adjusted for gender only.
Adjusted for age only.

Proportion of day spent on different activities

in cases and controls
The proportion of outliers excluded from this analyses was
6% in Kenya (<19 hours 4%, >29 hours 2%), 0.4% Bangladesh
(<19 hours 0.2%, >29 hours 0.2%) and 12% in The Philippines
(<19 hours10%, >29 hours 2%).
In all countries, cases spent less time on productive activities
compared to controls although in the Philippines there was little
difference in time spent on paid work between cases and controls
(Figure 2). Across the three countries the total proportion of the
previous day spent on productive activities by cases was 11%
(95%CI 1012) compared to 23% (95%CI 2127) by controls.
Cases spent a greater proportion of time on personal/self care
activities in all countries (p<0.001).
In Kenya time spent on leisure outside of the home was signif- Figure 1. Study sites.
icantly greater in controls (4%) compared to cases (2%), while

Ophthalmic Epidemiology NovemberDecember 2008 375

376
Table 2. Association between case/control status and participation in activities in the past week

Kenya Bangladesh The Philippines All countries combined

Participation in Age and gender Participation in Age and gender Participation in Age and gender Participation in Age, gender, SES,
last week adjusted last week adjusted last week adjusted last week country adjusted
Cases % Controls % OR (95% CI)* Cases % Controls % OR (95% CI)* Cases % Controls % OR (95% CI)* Cases % Controls % OR (95% CI)*
Activity n = 124 N = 139 n = 217 n = 280 n = 238 n = 163 n = 579 n = 582
Personal 100% 100% 100% 100% 100% 100% 100% 100%
Household 51% 74% 0.4 (0.20.7) 55% 89% 0.2 (0.10.3) 73% 90% 0.3 (0.2 0.6) 61% 86% 0.3 (0.20.4)
Paid work 3% 12% 0.3 (0.10.9) 5% 15% 0.4 (0.20.7) 12% 25% 0.5 (0.3, 08) 7% 17% 0.5 (0.30.7)
Work for own use 37% 64% 0.4 (0.20.6) 29% 63% 0.3 (0.20.4) 44% 72% 0.4 (0.2, 0.5) 37% 66% 0.4 (0.30.5)
Leisure outside home 36% 56% 0.5 (0.30.8) 32% 40% 0.8 (0.61.2) 32% 42% 0.7 (0.4, 1.0) 33% 44% 0.7 (0.50.8)
Leisure in the home 78% 85% 0.6 (0.31.1) 99% 100% 94% 95% 0.9 (0.4, 2.1) 92% 95% 0.6 (0.41.2
No particular activity 97% 92% 2.6 (0.88.9) 99% 100% 76% 89% 0.7 (0.3, 1.2) 93% 95%

*Odds ratio (OR) and 95% confidence intervals (CI) from multivariate logistic regression analysis comparing participation in activity by case/control status and adjusting for age and gender.
**Different trends observed between countries, therefore combined analysis not conducted.
A dashed line indicates that the cell sizes were too small for the calculation of odds ratio.
Table 3. Association between level of visual acuity and participation in activities during the past week among cases

Kenya Bangladesh The Philippines All countries

Participated in Participated in Participated in Participated in
activity in activity in activity in activity in
past week OR (95% CI)* past week OR (95% CI)* past week OR (95% CI)* past week OR (95% CI)*
Visual acuity % % % %
Household work
<6/246/60 67% Reference 77% Reference 87% Reference 77% Reference
<6/603/60 55% 0.7 (0.22.1) 68% 0.6 (0.21.7) 81% 0.6 (0.22.0) 70% 0.7 (0.41.2)
<3/60 >PL 50% 0.6 (0.22.2) 58% 0.3 (0.11.0) 74% 0.5 (0.21.3) 66% 0.6 (0.41.0)
PL 20% 0.1 (0.040.4) 34% 0.1 (0.00.2) 53% 0.2 0.10.5) 37% 0.2 (0.10.3)
p for trend 0.001 <0.001 <0.001 <0.001
Paid work
<6/246/60 2% 11% Reference** 16% Reference 10% Reference
<6/603/60 3% 7% 0.3 (0.11.0) 16% 0.7 (0.22.5) 10% 0.1 (0.42.1)
<3/60 >PL 8% 3% 11% 0.7 (0.32.1) 9% 0.8 (0.41.9)
PL 0% 1% 5% 0.3 (0.11.1) 2% 0.2 (0.10.6)
p for trend 0.03 0.09 0.003
Work for own use
<6/246/60 52% Reference** 45% Reference 53% Reference 50% Reference
<6/603/60 48% 0.9 (0.42.6) 27% 0.4 (0.21.0) 49% 0.2 (0.21.3) 41% 0.7 (0.41.1)
<3/60 > PL 29% 0.1 (0.10.5) 36% 0.6 (0.21.7) 49% 0.3 (0.31.5) 42% 0.7 (0.51.2)
PL 3% 17% 0.2 (0.10.5) 25% 0.3 (0.10.6) 18% 0.2 (0.10.4)
p for trend 0.001 0.001 0.004 <0.001
Leisure outside house**
<6/246/60 43% Reference 39% Reference 38% Reference
<6/60 3/60 45% 1.1 (0.53.1) 42% 1.1 (0.52.6) 35% 0.7 (0.31.6)
<3/60 > PL 42% 0.9 (0.32.4) 32% 0.7 (0.31.8) 26% 0.5 (0.31.1)
PL 10% 0.1 (0.00.) 24% 0.4 (0.20.9) 31% 0.7 (0.31.6)
p for trend 0.006 0.03 0.2
Leisure in home**
<6/246/60 80% Reference 98% 92%
<6/603/60 77% 0.9 (0.32.9) 100% 93%
<3/60 >PL 79% 0.8 (0.22.7) 100% 96%
PL 73% 0.7 (0.22.4) 98% 93%
p for trend 0.5
No particular activity
<6/246/60 96% 98% 77% Reference**
<6/603/60 100% 100% 84% 1.4 (0.44.8)
<3/60 > PL 92% 100% 87% 1.2 (1.511.8)
PL 100% 99% 97%
p for trend 0.005

*Odds ratios (OR) and p for trend values from logistic regression analyses with participation in last week as the outcome and moderate visual
impairment (MVI) as the reference value.
**Visual activity (VA) categories combined due to small cell sizes.
Different trends observed between countries, therefore combined analysis not conducted.
A dashed line indicates the cell sizes were too small for the calculation of odds ratios.
PL = perception of light.

in the Philippines cases spent a greater proportion of time on
leisure in the home (19%) compared to controls (13%) and in
Bangladesh there were no differences in leisure time. Cases spent
a greater proportion of the previous day on no activity in Kenya
(27%) and Bangladesh (24%) compared to controls (17% and
13% respectively), while in the Philippines there was no apparent
difference.
Proportion of day spent on different activities
among cases by level of visual acuity
In each country worsening VA was associated with reduced
proportion of time spent on productive activities (Table 4). In the
three countries combined, cases with MVI spent 16% (95%CI
1418%) of the day on productive activities compared to only
4% (95% CI 36%) in those with PL. This trend was driven
largely by the reduced time spent among people who were blind
or had PL, while there was no significant difference between
people with SVI or MVI. In Kenya and Bangladesh, the propor-
tion of the previous day spent on personal/self care activities and
no particular activity increased with worsening VA. In contrast,
in the Philippines worsening VA was associated with increased
time on leisure at home.
Assistance with activities
In all countries cases were significantly more likely to have
had assistance with any activity compared to controls (Table 5).

Ophthalmic Epidemiology NovemberDecember 2008 377

 Table 4. Proportion of time spent the previous day on different activities as a function of level of visual acuity

Kenya Bangladesh The Philippines All countries

Mean proportion of time Mean proportion of time Mean proportion of time Mean proportion of time
spent on activity during spent on activity during spent on activity during spent on activity during
previous day previous day previous day previous day
(95% CI) (95% CI) (95% CI) (95% CI)
Personal/self care
Controls: 6/18 42% (4044) 47% (4647) 35% (3437) 42% (4243)
Cases: < 6/246/60 47% (4550) 49% (4750) 39% (3641) 45% (4446)
<6/603/60 46% (4349) 48% (4750) 38% (3541) 44% (4346)
<3/60 >PL 50% (4653) 50% (4952) 38% (3640) 44% (4245)
PL 53% (4956) 51% (4952) 39% (3642) 47% (4549)
Household work
Controls: 6/18 10% (812) 12% (1113) 13% (1115) 12% (1113)
Cases: < 6/246/60 8% (611) 8% (610) 10% (712) 9% (710)
<6/603/60 7% (310) 7% (510) 12% (916) 9% (711)
<3/60 >PL 5% (29) 4% (26) 10% (813) 8% (711)
PL 3% (05) 3% (24) 3% (25) 3% (24)
Paid work
Controls: 6/18 2% (14) 3% (24) 4% (25) 3% (24)
Cases: < 6/246/60 0% (01) 1% (03) 4% (17) 2% (13)
<6/603/60 0% (00) 1% (03) 2% (05) 1% (02)
<3/60 >PL 1% (02) 0.1% (00.2) 1% (03) 1% (02)
PL 0% (00) 0.3% (01) 0% (01) 0% (01)
Work for own use
Controls: 6/18 12% (914) 6% (57) 8% (710) 8% (79)
Cases: < 6/246/60 6% (49) 4% (27) 5% (38) 5% (47)
<6/603/60 6% (310) 3% (05) 5% (38) 5% (36)
<3/60 >PL 3% (06) 2% (04) 5% (37) 4% (35)
PL 1% (01) 1% (02) 2% (13) 1% (12)
Leisure outside the home
Controls: 6/18 4% (36) 2% (23) 5% (36)
Cases: < 6/246/60 2% (13) 3% (14) 4% (26)
<6/603/60 3% (15) 2% (13) 4% (26)
<3/60 >PL 2% (04) 2% (14) 3% (25)
PL 0% (01) 2% (13) 4% (26)
Leisure in the home
Controls: 6/18 12% (1014) 14% (1315) 13% (1114)
Cases: < 6/246/60 12% (915) 14% (1216) 17% (1420)
<6/603/60 10% (713) 15% (1318) 17% (1321)
<3/60 >PL 12% (716) 18% (1521) 19% (1522)
PL 10% (714) 14% (1215) 21% (1725)
No particular activity
Controls: 6/18 17% (1419) 13% (1214) 20% (1722) 16% (1517)
Cases: < 6/246/60 23% (1927) 20% (1723) 18% (1322) 20% (1823)
<6/603/60 27% (2233) 22% (1825) 18% (1323) 22% (2025)
<3/60 >PL 28% (2234) 20% (1724) 20% (1525) 22% (1925)
PL 34% (2839) 28% (2531) 27% (2131) 29% (6230)

PL, Perception of Light.

Assistance was most common in the personal/self-care activities
where this was provided to 36% of cases in Bangladesh, 15% in
Kenya and 11% in the Philippines compared to 1%, 4% and 2%
controls. For activities other than personal/self care and leisure at
home, the proportion of cases who had assistance was relatively
low (<10%), partly reflecting the low numbers who participated
in these activities.
DISCUSSION
This study found a strong effect of visual impairment from
cataract on time-use patterns among adults aged 50 years
in three different low income countries. This effect was
independent of age, gender, SES and self-rated health. Over-
all, cases were less likely to engage in productive activities than
controls, and the lack of participation in productive activities
was most pronounced among those who were blind or only had
perception of light. These findings substantiate the wider im-
pact of cataract beyond individual quality of life, through loss
of productivity, with possible implications for the household
economy.911
The high proportion of people with normal vision involved in
productive activities highlights the important contribution this

378 NovemberDecember 2008 Ophthalmic Epidemiology

 Table 5. Percentage of cases visually impaired from cataract and controls with normal vision that had assistance with each activity group during the previous day

Kenya Bangladesh The Philippines

Cases Controls Cases Controls Cases Controls
Activity n = 139 n = 124 p-value* n = 217 n = 278 p- value* n = 238 n = 163 p-value*
Personal 15% 1% <0.001 36% 4% <0.001 11% 2% <0.001
Household/ domestic 10% 3% 0.01 9% 2% <0.001 4% 2% 0.3
Work (paid and own use) 4% 1% 0.1 5% 3% 0.3 4% 5% 0.6
Leisure (all) 3% 0% 0.1 15% 1% <0.001 6% 0% 0.002
Travel 2% 0% 0.3 4% 0% <0.001 4% 1% 0.03
Adjusted OR (95% CI) Adjusted OR (95% CI) Adjusted OR** (95% CI)
Overall: assistance in any activity 27% 3% 9.8 (3.3 to 29.8) 47% 9% 8.6 (5.1 to 14.4) 22% 9% 2.7 (1.4 to 5.1)

* p-value of difference between cases and controls from chi squared or Fishers exact test.
**Odds ratio (OR), adjusted for age and gender.

379
380
Figure 2. Mean proportion of time spent on each activity group during the previous day in cases visually impaired from cataract and controls
with normal vision. Graphs display 95% percent confidence intervals.
age group can potentially make to their household economy.
Since poverty among older people in Africa and Asia may be
related to an inability to satisfy social and economic roles,19 the
restrictive impact of cataract visual impairment on productive
and leisure activities may contribute to poverty in these settings.
The relationship between cataract and activities not in the
productive categories varied between countries, which is
likely to reflect cultural and socio-economic differences. In
Kenya and Bangladesh cases, particularly those with poorer VA,
spent more time doing no activity. In contrast, in The Philip-
pines there was no difference in no activity but cases spent
a greater proportion of time on leisure in the home. This may
reflect differences in perception of leisure or that in this wealth-
ier setting social support and provision of entertainment such as
TV/radio may be more common. In Kenya and The Philippines
and the three countries combined, cases were also less likely to
be engaged in leisure activities outside of the household. We are
not able to infer the direct impact on well-being from restricted
participation in productive activities and increased time in in-
activity. However, studies in high income settings have shown
that engagement in both productive14 and leisure20,21 activities
contributes to well-being among older adults.
Limited research has been conducted on this area which
would allow comparison. Our finding of increased time spent
in no activity in Kenya and Bangladesh concur with a study in
Nepal in which visually impaired men left their houses less fre-
quently and spent more time in quiet inactivity compared to men
with normal vision,13 and an Indian study where the majority of
people blind from cataract were unable to work.12
Cases in this study were more likely to have had assistance
compared to controls, indicating additional care-giving required
and potential lost opportunity costs for other household mem-
bers. Similarly, a study in India found a high proportion (75%)
of visually impaired people required assistance with everyday
tasks.12 However, the small numbers reporting assistance other
than for personal activities, indicates that the tendency was for
people not to participate at all rather than do so with assistance.
Despite the clear impact of cataract on productive activities
and need for assistance, this study demonstrated that some peo-
ple with visual impairment continued to be involved in produc-
tive activities, even people with perception of light. This sug-
gests that more conservative estimates of productivity losses for
people blind from cataract such as those used by Frick9 and
Shamanna10 may be more appropriate than 100% productivity
loss assumed by Smith and Smith11 .
Study limitations
This study had a number of limitations. The time-use data
assumed comprehension of the 24 hour clock system, although
pilot testing and discussions with interviewers after pilot in-
terviews suggested this was not problematic. The data relied
on accurate recall of the study subjects, and this ability may
be limited, particularly in this older population. Because of the
variation of reported time totals, the proportion of total reported
time rather than actual number of minutes was used for analysis.
Ophthalmic Epidemiology
Time allocation data were collected for a single day which
may not have represented a typical day. However, a reasonable
reflection of average daily time-use among cases and controls
overall could be obtained.Age matching of the cases and controls
could not always be achieved. Two different case recruitment
methods were used, although all cases were from the same dis-
trict and met the same case definition. The response rate was not
recorded for cases and controls, although refusal was believed
to be rare.
Finally, we were only able to undertake basic ophthalmic
examinations (using torch and direct ophthalmoscope in a dark
room) because of the nature of the fieldwork. It is acknowledged
that this may have lead to some over diagnosis of cataract as a
cause of visual impairment because other visually impairing co-
morbidities may not be detected by this examination method.
In summary, this study in three different countries demon-
strated that cases with visual impairment from cataract spent
less time than controls with normal vision on productive activ-
ities and were less likely to be engaged in leisure outside the
home. Cases also required more assistance. These findings were
most marked for individuals who had the most significantly im-
paired vision. The restrictive impact of visual impairment may
extend beyond individual well-being, by negatively affecting the
individual and household economy and contributing to poverty.
These findings suggest that cataract surgery may not only im-
prove individual quality of life, but also contribute to poverty
alleviation.
Study strengths
This was a multi-country study including a large sample of
population-based cases and controls interviewed in their own
homes. Study subjects were from randomly selected clusters
throughout the districts and were representative of the general
district population. Detailed standardized questionnaires were
used to collect in-depth information on time-use patterns, as well
as socio-demographic, economic and health factors. Similar key
patterns were observed in the three different countries lending
weight to the findings.
ACKNOWLEDGMENTS
The authors acknowledge funding support from Sight Savers
International, Christian Blind Mission and ORBIS International.
DECLARATION OF INTEREST
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the paper.
REFERENCES
1. Resnikoff S, Pascolini D, Etyaale D, et al. Global data on visual
impairment in the year 2002. Bull W. H. 2004;82:844851.
2. Foster A: Vision 2020: The cataract challenge. J commun. Eye
Health. 2000;13:1719.
NovemberDecember 2008 381
 3. Brown MM, Brown GC, Sharma S, et al. Quality of life asso-
ciated with unilateral and bilateral good vision. Ophthalmology.
2001;108:643647.
4. Pokharel GP, Selvaraj S, Ellwein LB. Visual functioning and quality
of life outcomes among cataract operated and unoperated blind
populations in Nepal. Br J Ophthalmol. 1998;82:606610.
5. Fletcher A, Vijaykumar V, Selvaraj S, et al: The Madurai Intraocular
Lens Study. III: Visual functioning and quality of life outcomes. Am
J Ophthalmol. 1998;125:2635.
6. He M, Xu J, Li S, Wu K et al. Visual acuity and quality of life in
patients with cataract in Doumen County, China. Ophthalmology.
1999;106:16091615.
7. Polack S, Kuper H, Mathenge W, et al: Cataract visual impair-
ment and quality of life in a Kenyan population. Br J Ophthalmol.
2007;91:927932.
8. Nutheti R, Shamanna BR, Nirmalan PK,et aL. Impact of impaired
vision and eye disease on quality of life in Andhra Pradesh. Invest
Ophthalmol Vis Sci. 2006;47:47424748.
9. Frick KD, Foster A. The magnitude and cost of global blindness:
An increasing problem that can be alleviated. Am J Ophthalmol.
2003;135:471476.
10. Shamanna BR, Dandona L, Rao GN. Economic burden of blind-
ness in India. Indian J Ophthalmol. 1998;46:169172.
11. Smith AF, Smith JG. The economic burden of global blindness: a
price too high! Br J Ophthalmol. 1996;80:276277.
12. Javitt J, Venkataswamy G, Sommer A. The economic and social
aspect of restoring sight. in Henkind P (ed.). ACTA: 24th Interna-
tional Congress of Ophthalmology. New York: JP Lippincott, 1983,
13081312.
382 NovemberDecember 2008 Ophthalmic Epidemiology
13. Beall CM, Goldstein MC: Age differences in sensory and cognitive
function in elderly Nepalese. J Gerontol. 1986;41:387389.
14. Baker L, Cahalin L, Gerst K et al. Productive activities and subjec-
tive well-being among older adults: The influence of the number of
activities and time commitment. Social Indicat Res. 2005;73:431
458.
15. Harvey AS, Taylor ME: Time Use. In Grosh M, Glewwe P, eds. De-
signing Household Survey Questionnaires for Developing Coun-
tries. Lessons from 15 Years Of the Living Standards Measure-
ment Study. Washington, dc: The World Bank, 2000, Volume 2,
249275.
16. Kuper H, Polack S, Limburg H. Rapid assessment of avoidable
blindness. Commun. Eye Health 2006;19:6869.
17. Turner AG, Magnani RJ, Shuaib M. A not quite as quick but much
cleaner alternative to the Expanded Programme on Immuniza-
tion (EPI) Cluster Survey design. Int J Epidemiol. 1996;25:198
203.
18. Filmer D, Pritchett L. Estimating wealth effects without expenditure
data - or tears. An application to educational enrollment in states
of India. Demography. 2001;38:115132.
19. Barrientos A, Gorman M, Heslop A. Old age poverty in developing
countries: contributions and dependence in later life. World De-
velop. 2003;31:557570.
20. Lampinen P, Heikkinen RL, Kauppinen M, et al. Activity as a pre-
dictor of mental well-being among older adults. Aging Ment Health.
2006;10:454466.
21. Steinkamp MW, Kelly JR. Social integration, leisure activity, and
life satisfaction in older adults: Activity theory revisited. Int J Aging
Hum Dev. 1987;25:293307.