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Increased life expectancy and improved socio-demographic status globally has seen more people live into adulthood, and seen a shift in the disease burden towards non-communicable diseases and disabilities.[1] However, the improvement in the health systems and service delivery mechanisms in most countries has been poor.[2] As we look beyond VISION 2020, there are many social determinants of health that need urgent attention if the priorities of the Sustainable Development Goals (SDGs) and universal eye health for all are to be a reality.
In 2020, an estimated 596 million people had distance vision impairment worldwide, of whom 43 million were blind. Another 510 million people had uncorrected near vision impairment.[3] Most studies have pointed to a disproportionate tilt in the ocular disease burden towards the females, whilst the trends in uptake of services and the health seeking behaviours were most evident amongst the male subjects. [4-6] This gender divide is particularly evident in low- and middle-income countries (LMIC). Very few researchers have attempted a formal comparison of the eye health of women and men. Many studies have been carried out either on all male samples or on mixed groups where findings from male and female subjects are not analysed separately. [4-6] A recent report on gender inequities in health problems indicated that five of the six eye conditions listed had a female to male excess of 1.2 or more.[7] This ratio holds true for almost all the preventable and treatable blinding conditions in the world.
To address the gender inequities in primary eye care, Mission for Vision in partnership with the Standard Charted Bank’s, Seeing is Believing initiative, has launched a novel initiative called Mission Jyot in 2019-2020.[8] As part of this, the uptake of primary eye care services and other regular parameters at all-women Vision Centres (VC) were assessed and compared with the standard VC model. This assessment describes a randomised trial designed to determine whether community-based VC screening comprising exclusively of women health workers improves uptake of services by women and girls in tribal and rural communities in Maharashtra state.
Four VCs were included in this comparative assessment comprising of two arms – (i) Intervention arm: Two VCs that are entirely manned and operated by women staff and (ii) Control arm: Two standard VCs manned and operated by male staff. The two VCs in the intervention arm are located in the Raigad district of Maharashtra, predominantly serving rural and tribal communities and are run by Khan Bahadur Haji Bachooali Charitable Ophthalmic & ENT Hospital, Mumbai. The two standard VCs in the control arm are located in Satara and Solapur districts, serving predominantly rural communities and are run by HV Desai Eye Hospital, Pune. The staff at each of these VCs include an optometrist, a supervisor and two community health workers (CHW). A pilot intervention involving direct home visits by trained CHWs, awareness generation and health education activities, conducting eye screening camps, and establishing linkages and networking with multiple stakeholders was undertaken. Outcomes were assessed after nine months, at the end of the financial year and included measuring total number of screenings done, refractions and cataracts identified and referred to base hospital for further evaluation and treatment. The socio-demographic and gender specific characteristics in each of the two arms were compared and reported.
During 2019-2020, the two VCs in the intervention arm screened a total of 9,730 clients combined, of which 5,563 (57.2%) were women and girls. The total number of refractions done and cataract cases identified and referred were 1,527 (15.7%) and 582 (6%) respectively, of which over 60% were women clients. In the control arm comprising the two standard VCs, a total of 20,542 clients were screened, of which 12,531 (61%) were male subjects. The total number of refractions done and cataract cases identified and referred were 1,706 (8.3%) and 462 (2.2%), of which about 61% were male clients. On the whole the uptake of screening services and identification of refractive errors and cataract cases were significantly higher amongst women clients at the VC that were manned and operated by female staff as compared to the standard VC, where the uptake of screening services was significantly highest for the male subjects.
In the intervention arm, recruiting two female CHWs from within the tribal community and training them has resulted in gaining the confidence of the community and has provided accessibility specifically to women. This in turn helped to fight gender inequalities in providing eye care services to women who usually do not seek eye care for themselves or their children, especially their daughters.
Once acceptability in the community was achieved, importance was laid on health education and communication. Health education in the community included: (i) basic eye care and hygiene, (ii) the causes and treatment of common eye diseases, (iii) prevention of eye injuries, (iv) basic first aid and (v) advice about when and where to seek professional healthcare. This was enabled by door-to-door screening. More tribal community members started visiting the eye screening camps too.
As general awareness on eye health and knowledge of VC increased, more members from the tribal communities started visiting the VCs of which about 60% were women. It is interesting to note that in the intervention arm, the number of refractive errors and cataract cases identified were highest amongst women and girls (over 60%) as against 40% in the standard VC which formed the control arm.
Running an all-women VC has resulted in gaining trust and acceptability and provided access. Tailor-made, novel interventions do yield desired outcomes in providing primary eye health services in geographies that are difficult to access. More of such novel interventions are needed to bridge the gender divide in primary eye care and to achieve the SDGs.
Image by Foram Hindocha
