Gender and blindness: eye disease and the use of eye care services

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Summary and Recommendations from a meeting at the Kilimanjaro Centre for Community Ophthalmology, Moshi, Tanzania, June 17-21, 2002

Blindness is an increasing global health problem that afflicts approximately 50 million people, two-thirds of whom are women, and ninety per cent of whom live in poorer countries. Much world blindness is due to cataract, routinely curable through surgery, or due to chronic trachoma infection, preventable through clean water and improved sanitation. The Vision 2020 initiative of the World Health Organization is addressing this problem through advocacy, planning and programming.

In poorer countries, women of all ages utilise eye care services much less than men. As a result, more women than men are blind or visually impaired from cataract, trachomatous trichiasis and angle closure glaucoma. To date, however, Vision 2020 programmes have not incorporated gender issues into evaluation, planning, or treatment efforts. Little applied research is available to help guide decisions in service provision.

Ophthalmic and women’s health researchers, policy makers and programme staff held a meeting in Moshi, Tanzania from 17-21 June, 2002 to discuss gender and blindness. The Kilimanjaro Centre for Community Ophthalmology (KCCO) at KCMC (Tumaini University) and the British Columbia Centre for Epidemiologic & International Ophthalmology (University of British Columbia) organised the conference, while a consortium of Canadian public health agencies sponsored the meeting. The participants identified key research, policy, and programme priorities listed below. A full report is available.

The participants agreed upon the following recommendations:

Policy Issues

1. Programme managers in all national and local blindness prevention programmes need to assess gender equity of service utilisation. This means separately assessing the potential barriers to use of services by men and women, throughout the life span.

2. Eye care agencies should follow WHO policy and critically evaluate gender roles within their own organisations, developing strategies to improve gender equity in the work environment.

3. Programme monitors need to incorporate sex specific indicators used for all eye care programme activities (e.g., cataract surgical rate, trichiasis surgical coverage). Leprosy control programmes should also monitor lagophthalmos and cataract surgical rates by sex.

4. Eye care service providers should encourage collaboration with non-health care programmes (e.g., water and sanitation) to improve environmental factors influencing women’s health.

Programme Issues

1. Eye care programme planners should direct most attention to the community level in order to gain long term trust and to involve community members in planning and providing prevention and treatment strategies. Programme planners should especially encourage women’s representation. This is a difficult and sensitive process requiring an understanding of local social, political and economic issues in their historical context.

2. Programme planners need to be aware that women often do not have decision-making power within communities. Programmes designed to increase utilisation of services by women, therefore, must include the people (often husbands or male community elders) who have decision-making authority. The goal is to empower communities to meet their eye care needs, not to achieve gender equity in the decision making process.

3. All cataract surgery facilities should have designated personnel (preferably, male and female) to provide good quality education for cataract surgery patients.

4. Eye care programme planners need to be aware of many different approaches to promote health education in a gender sensitive fashion within communities (e.g., school child health programmes, collaboration with traditional healers, women’s groups, local service groups).

5. Trachoma control activities need to emphasise facial cleanliness and environmental hygiene improvements (known as the ‘F and E’ components of the SAFE strategy), because these will be the most effective in long-term control of this disease, which affects primarily women.

Research issues

General

1. In each context (society/culture/religion) researchers need to:

• Clarify decision-making roles for accessing eye care
• Identify existing or potential social networks which support women needing eye care
• Define barriers and enabling factors to increase the use of eye care services by women and men
• Determine effective gender-sensitive methods to provide health information (regarding existing perceptions of surgery, primarily fatalistic attitudes and fear of surgery).

2. Researchers need to determine if the excess burden of blindness rates for women found in Africa, Asia and in industrialised countries is also found in Latin America and Eastern Europe/ Russia. In addition, researchers need to determine the specific causes of this excess blindness. Do these causes vary between the industrialised and non-industrialised countries?

Cataract

1. Epidemiologists and anthropologists need to clarify the factors that influence acceptance of cataract surgery by women. For example, do women accept cataract surgery more readily if counselled by female health workers, by other women who have had surgery, or by other community based groups?

2. Health services researchers need to determine how health sector reform and cost recovery affects service utilisation by men and women. What is the effect of marital status, education, family size, or other factors? What mechanisms can be put into place to ensure equity in utilisation?

3. Basic science researchers needed to understand better why women have a higher risk of developing cataract than men of a similar age.

Trachoma

1. Researchers need to clarify what the impacts of F and E will be on the roles and activities (e.g., use of time) of women?

2. Researchers need to determine if girls are re-infected more readily than boys following antibiotic distribution.

3. Researchers must determine which local community-based approaches best improve uptake (and equity in uptake by men and women) of trichiasis surgical services before vision loss occurs. Researchers must also examine whether women have a higher rate of recurrence of trichiasis following surgery and what can be done to reduce recurrence.

Childhood eye diseases

1. In each context, researchers need to determine what prompts parents to bring their children for surgery and when. Do mothers and fathers have different perceptions of the need of eye care for children and does this depend on the household structure or economic status? How do these perceptions affect utilisation of services?

2. Researchers need to explore why, in most settings, parents bring more boys for juvenile (non-traumatic) cataract surgery than girls. They must also study long-term follow up of children receiving surgery to assess utilisation and benefit of low vision services.

Other conditions

1. For glaucoma and other major causes of blindness, researchers need to clarify the utilisation of services and outcomes of service by men and women. Very little information exists to date on screening, medical and surgical services. In many settings there are more men than women receiving surgery.

2. For leprosy, researchers need to determine if the burden is similar for men and women and if more cosmetically appealing lagophthalmos surgery (compared to tarsorrhaphy) can improve socio-economic status or quality of life. Lagophthalmos is a significant cause of vision loss and disability in leprosy patients and is a burden on quality of life because of its stigmatising qualities.

For more information, please contact: Dr Paul Courtright Kilimanjaro Centre for Community Ophthalmology ([email protected]) or Dr Ken Bassett, British Columbia Centre for Epidemiologic & International Ophthalmology ([email protected])