An indigenous woman in Paraguay measures her vision. Photo by: Victor Cerda / Fundacion Vision / IAPB / CC BY-NC-SA

LONDON — Women and girls in low- and middle-income countries are disproportionately impacted by uncorrected vision impairment, untreated eye conditions, and blindness. This can further the gender imbalance many global development programs seek to tackle and requires addressing in eye-health programming from the start.

Women and girls make up 55 percent of the 250 million people globally who have an uncorrected vision impairment, with 89 percent of them living in LMICs, according to Imran Khan, chief global technical lead at Sightsavers. For severe vision loss, the inequity increases, with women accounting for two-thirds of all people classified as blind, he added.

The higher prevalence among women of some infectious diseases is partly due to traditional roles. For example, caring for children exposes women to hygiene risks that increase the chance of contracting trachoma, as does eye irritation caused by cooking over wood fires, explained Jennifer Gersbeck, director of global partnerships and advocacy at the Fred Hollows Foundation and co-chair of the gender equity work group at the International Agency for the Prevention of Blindness. Collecting water or washing clothes can also put women in greater contact with blackflies, whose bite transmits the parasite that causes onchocerciasis or river blindness.

Women’s access to preventive care, diagnosis, and treatment or correction is also lower than for men, meaning eye conditions are more likely to deteriorate, sometimes into permanent disability, added Tracy Vaughan-Gough, senior global technical lead for social inclusion at Sightsavers.

For example, women account for up to 80 percent of cases of trichiasis, the advanced stage of trachoma that leads to blindness, according to Gersbeck. Women are also far less likely than men to receive treatment for cataract, the world’s leading cause of blindness even in countries where this is available, Khan added.

The causes

The reasons are complex: Because women are less likely to be economically active, they tend to have less control over limited family budgets, while investing in the health of male current or future breadwinners is prioritized at their expense.

Family responsibilities also leave women with little time for accessing health services while safety risks and social taboos make it hard for some women to travel to clinics or hospitals or even to leave home unaccompanied.

Lower levels of literacy and increased social isolation can also reduce women’s ability to access information about how to prevent some eye conditions or what treatment and correction options are available.

Stigma around the wearing of spectacles is another barrier to women and girls having refractive error corrected. In South Asia, for example, girls can be viewed as “defective” — and therefore less likely to marry — rather than “effective" if they wear glasses, said Kristan Gross, global executive director at the Vision Impact Institute. In contrast, wearing spectacles is perceived as making boys look intelligent, she added.

The consequences

The consequences for women and girls in LMICs are profound. A lack of understanding around the causes of vision loss or impairment can foster discrimination that leads to girls being hidden by their families and women abandoned by their husbands or separated from their children, Vaughan-Gough said.

Women with disabilities are also more likely to experience sexual violence but less likely to be able to report it, especially if impaired vision makes it harder for them to describe their attacker, she added.

The links between poverty and blindness are well documented, with poverty sometimes causing poor eye health, while reversely, poor eye health can lead to or deepen poverty. And although this is also true for men and boys, women and girls suffer disproportionately, Gross noted.

The unexpected frontline detectors of poor vision

Are teachers the key to bridging the health worker gap and providing 700 million children with the required vision screening?

While children with vision loss in LMICs are already among the least likely to access education, vision-impaired girls — whose vision could in many cases be corrected with spectacles — are even less likely to attend school than vision-impaired boys, Gersbeck said. Without education, women and girls are less able to work and earn, more likely to suffer ill-health, and less likely to educate their own children, creating a poverty trap for entire families.

Lack of employment opportunities also renders visually impaired women less able to leave violent relationships, Gross said.

The solutions

Tackling the above challenges, both in terms of the prevalence of vision impairment among women and girls and the inequalities that poor eye health exacerbates, requires embedding gender in all eye-health programs from the outset, Vaughan-Gough said. This relies on the collection and analysis of gender-disaggregated data.

Case studies: Fred Hollows Foundation

► To identify the reasons for higher female cataract surgery dropout rates in Bangladesh, Fred Hollows conducted a survey of 30 female patients who had failed to continue treatment after visiting out-patient departments. Nearly a third cited financial hardship as a reason, while 1 in 6 said they did not have anyone to take them to hospital. It will use these results to help design future interventions and communication materials.

► The foundation’s Female Factory Workers project in Vietnam was launched on the back of a survey of 849 female factory workers that found more than 70 percent had a refractive error while up to 20 percent had other eye problems such as cataract or glaucoma. The project included the provision of training in eye care and exercises to 12,300 mostly female shoe factory workers, plus the production of short YouTube videos on eye-disease prevention for factories to show their workers. One year after the project, a random check of workers who had received spectacles or eye treatment found that 91 percent had good visual acuity.

Consulting with women and men — preferably in separate single-sex groups — is key to understanding women’s roles and gender dynamics in any community so that specific barriers to women accessing services can be identified, along with interventions that might work, she said. Men also need to be educated on ways they may be consciously or unconsciously disallowing women’s access to eye care, Gross advised.

For example, as part of the Coordinated Approach to Community Health, or CATCH, program in Uganda, Sightsavers recognized through early consultation a need to increase its trachoma screening during the dry season when women were less likely to be working in the fields and more available to take part.

Working with national governments is also imperative. Sightsavers and Fred Hollows have both cooperated with the government of Pakistan to integrate eye care into its Lady Health Worker program, which trains female health workers — including doctors, nurses, and optometrists — to provide care to women and children in their communities.

Women in Pakistan are typically more comfortable seeking diagnosis or treatment from a female worker while awareness-raising campaigns may not reach women living in purdah, or seclusion, without home visits. Improved rural access also helps women with vision impairment overcome challenges related to mobility and transport costs, Khan explained.

To ensure that no one is left behind, the development community will need to address the way it approaches visual impairment in women and girls, leveraging more cross-sector partnerships to attack challenges from every angle.

For example, the School Health Integrated Programming, which trains teachers to screen children for vision problems and then provides spectacles or treatment as required, was funded through the World Bank and the Global Partnership for Education not as a health program but as an education program, he notes. It also screens and treats the mostly female teachers, meaning boys, girls, and their families become used to seeing educated women in positions of influence wearing glasses.

“We just stop looking at visual impairment in women and girls as strictly a health issue but an education issue, a financial issue, and a wider societal issue,” Khan concluded.

Devex, with financial support from our partner Essilor, is exploring challenges, solutions, and innovations in eye care and vision. Visit the Focus on: Vision page for more.

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    Helen Castell

    Helen Castell is a London-based financial journalist with nearly 20 years’ experience covering trade, energy and risk for TXF, Shares Magazine, Global Trade Review, Newsbase, Trade Finance Magazine and other Euromoney publications. At Devex, she writes about development banking, private sector engagement and funding trends. She studied English Literature at Sheffield University and International Journalism at London’s City University, and speaks English, Spanish and Japanese.