1. 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)

2. Why are we here? What do we hope to accomplish today?

3. 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

4. A bit of history….Understanding the problem & generating the evidence for action 1.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

5. 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.

6. 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

7. 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

8. Cataract

9. Cataract Surgical Coverage (2002-8) ** CSC calculated at 6/60 Lewallen et al, BJO 2009;93:295-8

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

11. 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

12. Key strategies for cataract Transport to hospital Counseling of family members Women-to-women contact

13. Childhood blindness Vitamin A/measles related corneal opacities now rare Retinal/optic nerve conditions increasing Childhood cataract –Congenital –Developmental –Traumatic

14. Still too few girls getting surgery Children receiving surgery for congenital/developmental cataract at tertiary eye hospitals

15. Trachoma Excess burden of trichiasis in women compared to men 1.82 (95% CI 1.6 to 2.1)

16. 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%)

17. Why are we here? What do we hope to accomplish today?

18. 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

19. 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

20. Improving gender equity = Reducing blindness