1. Is access to the SAFE strategy equal for men and women?
Paul Courtright, DrPH
Kilimanjaro Centre for Community Ophthalmology
Tumaini University/KCMC, Moshi, Tanzania

2. “…state of being easy to approach or enter…”
Access
“…state of being easy to approach or enter…”
Accessible
“…easily approached or entered…”

3. Burden of blindness in the population (all surveys)

4. Findings from systematic review
Age-adjusted odds of blindness in women compared to men
Africa: ( )
Asia: ( )
Industrialised: ( )
Overall: ( )
Abou-Gareeb et al. Gender and blindness: a meta-analysis of population-based prevalence surveys. Ophthal Epidem. 2001;8:39-56.

5. 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
Higher incidence of cataract among women
Higher incidence of trachomatous trichiasis among women
Unequal utilisation of eye care services

6. Cataract Surgical Coverage
Lewallen & Courtright. Gender & use of cataract surgical services in developing countries. Bull WHO. 2002;80:300-3

7. Does trachoma need to be considered a gendered health issue?

8. Observations
In many (not all) settings, females have higher prevalence of active disease
Women account for 60-85% of trichiasis cases (2-3 times higher than men)
Blindness due to trachoma about 3 times higher in women compared to men.

9. Trachomatous trichiasis in Menia governorate, Egypt

10. Trachoma as a cause of vision loss and blindness in Ethiopia

11. Why do women bear an excess burden of blindness due to trachoma?
Are girls more likely to acquire active disease (infection) compared to boys?
Do girls have more persistent infection compared to boys?
Are their biologic reasons for the differences?
Could the differences be due to gender roles which facilitate transmission?
Are there differences in the utilisation of surgical services for trichiasis?

12. Is access to the SAFE strategy equal for men and women?
Surgery
Antibiotics
Face washing & environmental changes

13. Is access to Surgery equal for men and women?
Burden of need primarily for women
Measurable?
Need baseline data to know burden by sex
Need to monitor separately for men and women
Current evidence:
Yes….if….
….there are community-based efforts to encourage/enable use of trichiasis surgical services

14. Sr. Kileo examining for trichiasis in Ormelili village

15. Barriers to use of eye care services are different for men & women
Cost of using service (access to financial resources)
distance to services (ability to travel and need for assistance)
knowledge of service (awareness and literacy)
perceived “value” (social support)
fear of a poor outcome (cosmesis)

16. Masai woman with combined trichiasis & cataract surgery

17. Is access to Antibiotics equal for men and women?
Access depends upon distribution mechanism
Mass vs. targeted
Management with other NTD?
Access depends on community characteristics
When promotion inadequate: can be sex-specific non-acceptance
Gender roles constructed by culture & religion

18. Is access to Antibiotics equal for men and women?
Measurable?
Need coverage data reported by sex
Current evidence lacking
Supposition that poor coverage due to providers rather than recipients

19. Who will bear the burden of the cost of antibiotic treatment?
Tanzania willingness to pay (WTP) study showed:
>1/3 of respondents would not be willing to pay for antibiotic
Those at higher risk of trachoma were willing to pay less for future treatment
Female-headed households unwilling to pay (=
-0.7)
Maternal education predictive of willing to pay

20. Is access to F & E equal for men and women?
When water is scarce, who decides how it is used?
Who is responsible for ensuring facial cleanliness?

21. Understanding access to F & E requires:
Understanding decision making at the community and the household level
Gender roles in enabling (or disabling) community development
Understanding how changes occur

22. Some reasons our health education efforts fail
Messages are not addressed to the right audience
Media used for knowledge transfer used not appropriate for audience or message
Over-reliance upon single strategies
Women often not “enabled” to make behavioral or infrastructure changes

23. Potential areas of research
What is needed to scale up trichiasis surgery (remembering that 60-80% of surgical need is among women)?
What factors contribute to low antibiotic coverage—and what is needed to ensure high coverage?
Can community-directed strategies for improving F & E reduce the burden of trachoma in communities (and how do we enable women to adopt these strategies?)

24. Family in Guinea-Bissau with trachoma

25. If we are going to reach our GET 2020 targets we must ensure that our programmes are gender-sensitive