Gender and eye care: Evidence of the problem and

solutions

Paul Courtright, DrPH

Kilimanjaro Centre for Community Ophthalmology

Cape Town, South Africa & Moshi, Tanzania

(www.kcco.net)

Why are we here?

What do we hope to accomplish today?

Why are we here?

Women account for 2 out of 3 blind people….

…if we are to achieve VISION 2020 we must address eye care needs of

women

A bit of history….Understanding the problem & generating the evidence

for action1. Systematic review of literature & meta-analysis

2. Analysis of potential reasons for differences in blindness figures

3. Disease specific assessments (including measuring service utilization)

4. Implementing strategies to address the issues

Findings from meta-analysis of 70 population based surveys

(published between 1980-2000)

Age-adjusted odds of blindness in women compared to men

– Africa: 1.39 (1.2-1.6)– Asia: 1.41 (1.3-1.6)– Industrialised: 1.63 (1.3-2.1)

– Overall: 1.43 (1.3-1.5)

Abou-Gareeb et al. Ophthal Epidem. 2001;8:39-56.

What about the last 12 years?

• Large national surveys (Ethiopia, Pakistan, Bangladesh & Nigeria)

• Rapid Assessment of Avoidable Blindness (RAAB) surveys (about 28 in Africa)

• Indian (state) RAAB surveys

• Latin American RAAB surveys

Analysis of potential reasons for gender disparity

• Longer life expectancy in women – Women live longer and blindness is associated with

increasing age.– However, age-specific rates of blindness show female

excess in most age groups

• Different risk for acquiring eye diseases– Slightly higher incidence of cataract among women– Higher incidence of trachomatous trichiasis among

women

• Unequal utilisation of eye care services– Cataract, trachoma, congenital/ developmental cataract

Cataract

Cataract Surgical Coverage (2002-8)

0%20%

40%60%

80%100%

Males Females

** CSC calculated at 6/60

Lewallen et al, BJO 2009;93:295-8

CSC (by person) for men & women at <3/60 (ranked by highest to lowest overall CSC)

-15-10-505

101520253035

Sudan

(N)

Kenya

(Nak

uru)

Kenya

(Kwal

e)

Sudan

(W N

ile)

Sudan

(Sen

)

Tz (Kili)

Ugand

a (N

tug)

Eritre

a

Mad

agas

(Atsi

n)

Sudan

(N K

hor)

Sudan

(Kas

s)

TZ (Z

anz)

Mal

i (Kou

l)

Kenya

(S N

yan)

Rwanda

(W)

Mal

awi

RSA (E C

ape)

Burun

di (N

)

Difference

Higher in men

Higher in women

Why are women less likely to have surgery?

• Perceived need for eye care different

• Willingness to assume a “sick” role

• Financial decision-making in the family

• Inexperience in traveling outside the village

• Social support lacking

Key strategies for cataract

• Transport to hospital

• Counseling of family members

• Women-to-women contact

Childhood blindness

• Vitamin A/measles related corneal opacities now rare

• Retinal/optic nerve conditions increasing

• Childhood cataract– Congenital– Developmental– Traumatic

Still too few girls getting surgery

0

10

20

30

40

50

60

70

80

Malawi Kenya TanzaniaKCMC &CCBRT

India

GirlsBoys

Children receiving surgery for congenital/developmental cataract at tertiary eye hospitals

Trachoma

• Excess burden of trichiasis in women compared to men 1.82 (95% CI1.6 to 2.1)

Surveys represent burden of TT globally?

• Total survey sample = 43,677– Men = 19,392– Women = 24,285

• People with TT = 9,564– Men = 2,826 (29.5%)– Women = 6,738 (70.5%)

Men

Women

Why are we here?

What do we hope to accomplish today?

How do we reduce gender inequity?

A disease specific approach?

•Cataract

•Trachoma

•Childhood blindness

A service delivery approach?

•Interacting at the community level

•Changing our eye care facilities

•Bridging communities and facilities

How do we reduce gender inequity?

A disease specific approach?

•Cataract

•Trachoma

•Childhood blindness

A service delivery approach?

•Interacting at the community level

•Changing our eye care facilities

•Bridging communities and facilities

Improving gender equity =

Reducing blindness