Cataract Surgery in Nigeria

: An investigation of Functional Quality as seen from the Surgeon’s Perspective

Abstract

Background: The prevalence of blindness from cataract is growing in Africa, and reported outcomes of cataract surgery are substantially suboptimal. Despite the poor outcomes, studies of the quality of cataract surgery in Africa are lacking. This study sought to investigate the functional quality of cataract surgery in Nigeria, as seen from the surgeons’ perspectives.

Method: Mixed-method study with convergent parallel design using survey questionnaires and in-depth interviews. A grounded theory of cataract surgery quality was created from the interview data. A SERVQUAL tool compared the experiences and perceptions of surgeons within five dimensions of functional quality metrics from the survey data.

Analysis: Sixty-one participants met the inclusion criteria of the study and completed questionnaires. SPSS (IBM Statistics version 30.0.0) was used for statistical analysis of survey responses. Nine participants took part in interviews that were analysed for snippets, concepts, codes, and categories until theoretical saturation was reached and a theory created. The Cullens’ Framework and the Delve approach to grounded theory analysis were used as guides to analyse the interview data, creating data structures.

Findings: The results of this study suggest that the functional quality of cataract surgery in Nigeria is optimal. Surgeons are responsive in their care; they are empathetic, and outcomes are highly reliable. Five interrelated categories were identified: Inherent, Clinical, Resource, Process, and Governance. The Inherent category, surgeons’ values, motivations, professional identity, and risk tolerance, emerged as the core category linking all others. These relationships formed the Integrated Quality and Access Framework (IQAF), which explains how cataract surgery outcomes arise from the dynamic interplay between surgeons’ intrinsic attributes and the wider health system environment. Significant expectation–perception gaps, with the SERVQUAL were observed. The largest gap score was in the Assurance dimension (- 0.43), Responsiveness (- 0.26), and Empathy (-0.25) showed moderate shortfalls, Reliability (-0.21) and Tangibles (-0.19) showed smaller average gaps. The Related Sample Wilcoxon Signed Rank Test in Responsiveness, Assurance, and Empathy showed gaps (p < .05). No significant gaps were found in Tangibles (p = 0.16) or Reliability (p = 0.08). SERVQUAL data and grounded theory analysis revealed that the functional quality of cataract surgery in Nigeria is influenced by a complex interplay of governance structures, resource management, human capital development, and patient-centred practices. Therefore, functional quality is not a direct predictor of technical quality. Social Cognitive Theory underpinned the study findings as it explained how cataract surgery outcomes in Nigeria emerge from the reciprocal interaction of surgeons’ self‑efficacy, their behavioural adaptations, and the structural constraints of the health system.

Conclusions: Although notable improvements have been observed in cataract surgery outcomes in Nigeria over the past decade, significant challenges persist. Addressing these issues requires a comprehensive approach that encompasses patient education, infrastructural enhancements, and ongoing training for healthcare providers. This study moves beyond descriptive accounts of poor outcomes to offer a deeper, more explanatory understanding of how quality is produced and how it might be improved. By addressing both clinical and systemic challenges as presented in the integrated quality and access framework, the potential for improved visual outcomes in patients can be realised, ultimately enhancing the overall quality of eye care.

Date of Award	22 Apr 2026
Original language	English
Awarding Institution	University of Bath
Supervisor	Momna Hejmadi (Supervisor) & Denize Atan (Supervisor)