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

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

Burden of blindness in the population (all surveys)

Findings from systematic review 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. Gender and blindness: a meta-analysis of population-based prevalence surveys. Ophthal Epidem. 2001;8:39-56.

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

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

Does trachoma need to be considered a gendered health issue?

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.

Trachomatous trichiasis in Menia governorate, Egypt

Trachoma as a cause of vision loss and blindness in Ethiopia

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?

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

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

Sr. Kileo examining for trichiasis in Ormelili village

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)

Masai woman with combined trichiasis & cataract surgery

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

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

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

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?

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

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

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?)

Family in Guinea-Bissau with trachoma

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