Inequalities

Poor vision contributes to gender inequalities.

Inequalities related to vision loss and access to eye health services persist across many areas and are often masked by national averages. Vision loss is both a contributor to inequalities and is also an outcome of inequality.

Key evidence from The Lancet Global Health Commission on Global Eye Health:

In some settings the higher rates of vision loss experienced by women is socially determined
- After adjustment for demographic differences, there are 108 women with blindness for every 100 men. The persistent gender difference suggests that, in some settings, the greater vision loss experienced by women is socially determined.¹
Women, rural populations and minority ethnic groups are more likely to have vision impairment
- The eye health sector has underutilised health promotion and prevention strategies to lessen the impact of eye disease and reduce inequality.²
Improving eye health contributes to increased gender equity (SDG5) and reduced inequalities (SDG10)
- Training community volunteers to identify and counsel affected individuals, and empower them to circumvent or challenge socio- economic barriers may reduce gender inequity in vision loss.³

Poor vision contributes to inequalities for marginalised and socially disadvantaged populations

Persistent inequity must be addressed for UHC for eye care to be realised.

Key evidence from the Commission:

Access to eye care is not equally distributed between and within countries
- In many high-income countries, the most marginalised subgroups of the population, such as Indigenous people or other non-dominant ethnic groups, are left behind.¹
Effective interventions address multiple dimensions of access concurrently
- There are many potential approaches to reduce inequity, given the complex nature of health care access. The most effective interventions address multiple access dimensions concurrently, often from both the service and patient perspectives.^4,5
A promising strategy in pursuit of UHC for eye care is proportionate universalism
- Proportionate universalism aims to improve outcomes for all population groups but targets disadvantaged groups. This ensures that improvement flows proportionate to the level of need at the outset, with the greatest benefit in the most disadvantaged.⁶

Poor vision contributes to inequalities for older adults.

Inequalities related to vision loss and access to eye health services persist across many areas and are often masked by national averages. Vision loss is both a contributor to inequalities and is also an outcome of inequality.

Key evidence from the Commission:

Older people are the most affected by vision loss
- 73% of people with vision loss are aged 50 years and older. Rates of vision loss increase quickly every decade above 50 years.⁷
Targeted interventions can increase access for older people
- Specific interventions such as community outreach vision screening services increase equity in eye health among women, marginalised communities and older people.^8,9
Dual sensory impairment is an important consideration for healthy ageing as global populations grow older
- Like vision loss, hearing impairment is associated with age. When these two conditions occur concurrently there is a dual sensory impairment, which is an important consideration for healthy ageing as global populations grow older.¹⁰
Falls are the leading cause of injury-related death among adults over 70 years globally
- One third of people aged over 65 years fall each year.^11,12Vision impairment is an independent risk factor for falls among older adults. Timely access to ophthalmic interventions such as cataract surgery can reduce fall risk.^13–15
- The Commission calls for vision to be included in falls risk assessment tools and for eye care services to be better integrated with falls prevention efforts.¹

Greater equity, diversity and inclusion is needed in the eye health sector

Diversity and inclusion benefit individuals, organisations, teams and society.

Key evidence from the Commission:

The eye health sector is lagging behind the broader development sector on gender parity
- Only 28.3% of eye health organisations boards are held by females, with ethnic minority women holding the fewest leadership positions.¹⁶
The eye health research sector falls short of gender parity
- Although female authorship has increased since 2000, females only hold 36% of first authorship and 24% of last (“senior”) authorships. Females held just 11% of editor-in-chief positions.

Burton, M., Ramke, J., Marques, A., Bourne, R., Congdon, N., Jones, I. et al. Lancet Global Health Commission on Global Eye Health: Vision Beyond 2020. The Lancet Global Health (2021).
Assi, L. et al. Eye Health and Quality of Life: A Global Assessment Through A Systematic Review of Systematic Reviews. Press (2021).
Mercer, G. D., Lyons, P. & Bassett, K. Interventions to improve gender equity in eye care in low-middle income countries: A systematic review. Ophthalmic Epidemiol. 26, 189–99 (2019).
Burn, H. et al. Eye care delivery models to improve access to eye care for Indigenous peoples in high income countries: protocol for a scoping review. BMJ Open 9, (2019).
Hamm, L. M. et al. Interventions to promote access to eye care for non-Indigenous, non-dominant ethnic groups in high-income countries: a scoping review protocol. BMJ Open 10, e033775 (2020).
Gwatkin, D. R. & Ergo, A. Universal health coverage: Friend or foe of health equity? The Lancet vol. 377 2160–2161 (2011).
Bourne, R. et al. Trends in prevalence of blindness and distance and near vision impairment over 30 years: an analysis for the Global Burden of Disease Study. Lancet Glob. Heal. (2021) doi:10.1016/S2214-109X(20)30425-3.
Liang, Y. et al. Effect of Community Screening on the Demographic Makeup and Clinical Severity of Glaucoma Patients Receiving Care in Urban China. Am. J. Ophthalmol. 195, 1–7 (2018).
Zhang, M. et al. Impact of cataract screening outreach in Rural China. Investig. Ophthalmol. Vis. Sci. 51, 110–114 (2010).
Heine, C. & Browning, C. Dual Sensory Loss in Older Adults: A Systematic Review. Gerontologist 55, 913–928 (2015).
World Health Organization. WHO Global Report on Falls Prevention in Older Age. https://www.who.int/ageing/publications/Falls_prevention7March.pdf?ua=1
GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 Diseases and Injuries for 195 countries and territories, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet 392, 1789–1858 (2018).
Harwood, R. H. et al. Falls and health status in elderly women following first eye cataract surgery: A randomised controlled trial. Br. J. Ophthalmol. 89, 53–59 (2005).
Meuleners, L. B., Fraser, M. L., Ng, J. & Morlet, N. The impact of first- and second-eye cataract surgery on injurious falls that require hospitalisation: a whole-population study. Age Ageing 43, 341–346 (2014).
Tseng, V. L., Yu, F., Lum, F. & Coleman, A. L. Risk of fractures following cataract surgery in medicare beneficiaries. JAMA – J. Am. Med. Assoc. 308, 493–501 (2012).
Yashadhana, A. et al. Action needed to improve equity and diversity in global eye health leadership. Eye 34, 1051–1054 (2020).