PURPOSE. China has among the lowest cataract surgical rates in Asia. This study was conducted to identify barriers to cataract surgery in rural China. METHODS. All subjects having undergone cataract surgery and persons with presenting visual acuity <= 6/60 (in Yangjiang) or <= 6/18 (in Handan) in >= 1 eye due to nonsurgically treated cataract were identified in two population-based studies in southern (Yangjiang) and northern (Handan) China. The subjects were administered a questionnaire assessing attitudes in four areas constituting potential barriers to surgery: knowledge about cataract, perceptions of local surgical quality, transportation and cost, and available resources. RESULTS. Interviews were completed on 71% to 86% of eligible subjects in both sites. Interviewed subjects did not differ significantly from nonrespondents with regard to age, sex, and presenting acuity in the better-seeing eye. A total of 214 (80.4%) nonsurgical and 131 (76.6%) surgical participants were interviewed, with a mean age of 71.8 +/- 8.0 and 73.7 +/- 7.4 years, respectively (P > 0.1). Among the nonsurgical subjects, 67.8% were blind (presenting vision, <= 6/60) in >= 1 eye due to cataract, whereas among the surgical participants, 25.2% remained blind in the eye that had undergone surgical removal of the cataract. In a multivariate analysis adjusted for age, sex, and site, increased knowledge and higher estimates of the quality of surgery were associated with having had surgery, whereas cost and transportation scores were not. CONCLUSIONS. Lack of knowledge about cataract and concerns about the quality of local services appear to be the principal barriers to cataract surgery in rural China. (Invest Ophthalmol Vis Sci. 2009; 50: 1069-1075) DOI: 10.1167/iovs.08-2783