Increasing uptake of eye services by women
Is there a problem for women?
It often surprises people, but it’s no secret to eye health workers in poor countries, that patients who live with blindness and low vision in these countries often do not make use of existing services. Many programmes, particularly in Africa, struggle to get patients in for surgery. How many eye health workers also know that the problems of access and acceptance are generally worse for women than for men and that women comprise a disproportionate number of the world’s blind?
Figure 1 shows the proportion of blind who are female in Asia and Africa.1 Why does this imbalance occur?
It is well established that the major cause of blindness in poor countries is cataract. Figure 2 is derived from population-based surveys in several countries and shows that 60 to 65 per cent of those blind from cataract are female. This is partly because women live longer than men and thus are more likely to develop cataract. In addition, women have been shown to have a slightly increased ageadjusted risk of cataract.2 Cataract blindness, however, can be cured, or even prevented if the operation is done early enough, and herein lies the crucial imbalance: women do not receive cataract surgery at the same rate as men. Figure 3 shows the cataract surgical coverage (which measures the proportion of the need for cataract surgery in the community that is being met) reported in a number of studies. These coverage figures are higher for men.3-5
This inequity is often overlooked because most programmes report about the same number of cataract operations performed in women as in men. The chances are, if you look at the records of your hospital, you will find a 50/50 split by gender in the number of cataract operations. However, since women have more cataract to begin with, we should perform about 60-65 per cent of our cataract surgery in women, if we are to achieve equality in cataract surgical coverage for men and women. We find similar inequity in glaucoma. Chronic open-angle glaucoma (COAG) is the second leading cause of blindness in sub-Saharan Africa. It occurs equally often in males and females, yet males comprise around 70 per cent of new COAG patients at the two largest referral eye clinics in Tanzania6 (also authors’ own data).
Hospitals and clinics are not deliberately discriminating against women, but women face special problems in accessing services. We need to consider these in order to plan solutions.
What special problems do women face?
The Community Eye Health Journal has published articles discussing barriers that prevent patients from accessing services. We like to think of barriers occurring at three levels: lack of awareness of services, lack of access to services, and reluctance to accept services. All three of these types of barriers tend to affect women more than men. Consider the following:
Women are less likely to be educated than men. They are therefore less likely to be aware that some blindness can be cured, to know where to go, and to know how to get there. Elderly women, with little or no formal education or exposure to hospital settings, may have more concerns and questions than men regarding surgery. Language barriers or unfamiliarity with the health system can lead to decreased awareness of health care services by some women.
Travelling away from home for surgery is hard for all old people, but it is often more difficult for women. In many cultures, women have little money or control over how money is spent. Many elderly people depend mostly on their children to cover the costs of cataract surgery. We found in Tanzania that young heads of households are less likely to encourage and support old women to go for surgery than old men. In many cultures women cannot travel unless accompanied by a male, and the lack of someone to accompany them can also be a barrier.
Quality of life expectations in old age are gender-specific in some cultures and the perceived ‘benefit’ of cataract surgery may be gender-dependent. For instance, elderly men expect and are expected to participate in community meetings; their involvement requires mobility. Women, on the other hand, may be more confined to the house.
In summary, men and women all face the same barriers, but many of these are more difficult for women to overcome.
How do we help women have access to services?
Our experience in developing and studying VISION 2020 programmes in eastern Africa indicates that several essential components must be in place if a ‘community’ is to have access to an eye care service. These are shown in Figure 4. We have found two specific components to be especially important to ensure care for women: transportation and counselling. Both can be built into whatever strategy the programme uses to establish a ‘bridge’ between the hospital services and the community.
Hospitals are still widely scattered in resource-poor countries and patients often cite distance as a barrier. Either the surgical team has to go to the patients or the patients must come to the surgical team. We have found that females are significantly more likely than males to access services through programmes that provide transport from rural areas; they are less likely to come to the hospital on their own.
This task is often assumed to be done by nurses. Sometimes it is, but more often it is neglected or given little attention in a busy clinic or screening session, where a nurse has other duties to perform. It is preferable to have one person solely dedicated to the counselling task during the clinic or screening session; this ensures that patients and their families really have a chance to have their questions answered. Accepting surgery is a family decision and engaging the family through good quality counselling is essential. The counsellor needs to be very familiar with all aspects of the process. What will happen in the hospital? Will the patient be alone? Is surgery painful? How long is the hospital stay? How will the patient get back home? How much will it cost for surgery and ‘extras’? What if the patient wants to wait until next month? Patients need answers to these questions before they can agree to surgery.
In addition, there are other ways in which programmes can target women. Special educational programmes with women’s groups help to raise awareness among women about eye health. When women meet other women who have had successful surgery, they are more likely to accept surgery themselves. And let us not forget that men – husbands, brothers, and sons of visually impaired women – are always part of the decision-making process. They need to know that women have the same ‘right to sight’ as men do.
1 Abou-Gareeb I, Lewallen S, Bassett K, Courtright P. Gender and blindness: a meta-analysis of populationbased prevalence surveys. Ophthalmic Epidemiol 2001;8(1): 39-56.
2 Congdon N and Taylor HR. Age-related cataract. In: Johnson GJ, Minassian D, Weale RA, West S, editors. The Epidemiology of Eye Disease. New York: Arnold, 2003: 105-119.
3 Lewallen S, Courtright P. Gender and use of cataract surgical services in developing countries. Bull World Health Organ 2002;80(4): 300-303.
4 Anjum KM, Qureshi MB, Khan MA, Jan N, Ali A, Ahmad K et al. Cataract blindness and visual outcome of cataract surgery in a tribal area in Pakistan. Br J Ophthalmol 2006;90(2): 135-138.
5 Bassett KL, Noertjojo K, Liu L, Wang FS, Tenzing C, Wilkie A et al. Cataract surgical coverage and outcome in the Tibet Autonomous Region of China. Br J Ophthalmol 2005;89(1): 5-9.
6 Mafwiri M, Bowman RJ, Wood M, Kabiru J. Primary open-angle glaucoma presentation at a tertiary unit in Africa: intraocular pressure levels and visual status. Ophthalmic Epidemiol 2005;12(5): 299-302.