Gender and Blindness: The conditions do matter: differences in use of services for

cataract and trichiasis after implementation of a community based

eye health programme

Ahmed Mousa Abdel Rahim, M. Sc., Ph. D.Lecturer, Ocular Epidemiology,Department of Ophthalmology,College of Medicine, King Saud University, Riyadh, Saudi Arabia.

Major Goal:To increase eye care service utilization by women in rural Upper Egypt.

Achievable through

• Increase the awareness of avoidable blindness.

• Increase surgical uptake of cataract and trachomatous trichiasis. • Build the capacity of local eye care providers.

• Decrease the impact of barriers

Methods:

Intervention

Control

40 K

M

Capital and Hospital

Major Model Components:Conduct of Community Health Education

Screening and Referral of Eligible Cases

Capacity Building of Local Eye Care Providers

Breaking Down Barriers to Service Utilization

Helping People to Seek Service

Decrease the Blindness Burden

Seven Health Education Messages

Magnitude and causes of avoidable blindness (with a special referral to the area).

Identification of the two main targeted diseases; Cataract Trichiasis.

Hygiene issues and maintaining good eye health.

Detailed message about cataract including; different types, causes, manifestations and availability of treatment (surgical procedures).

Detailed message about trachoma in children; infection, causes, prevention, complications, and treatment.

Detailed message about Trichiasis and its causes, treatment and complications.

Specific message about gender issues, why we focus on females and the impact of reducing gender gap.

Results:

69%

31%

KnowledgeKnow About Cataract and Or TTNever Heard

31%

53%

16%

AttitudePrefer Private Sector Prefer Local ServiceOther Providers

23%

77%

PracticeSought Service Never Did

The KAP Gap

Results: Comparing Pre to Post Intervention Prevalence of Low Vision and Blindness.

Normal VI & SVI Blind

60.10%

30.40%

9.30%

73.40%

24.20%

2.30%

Intervention VillagesPre Intervention Post Intervention

Normal VI & SVI Blind

60.90%

30.20%

8.90%

63.70%

31.40%

4.90%

Control VillagesPre Intervention Post Intervention

Male Female Male Female

67.60%

55.10%

81.00%

68.60%

26.70%

32.90%

18.00%

28.20%

6%

12%

1%3%

Normal LV & SLV Blind

Results: Comparing Pre to Post Intervention Gender Specific Prevalence of Low Vision and Blindness

(Intervention Villages).

Pre Intervention Post Intervention

Results: Comparing Pre to Post Intervention Prevalence of Cataract

86%

14%

69%

31%

69%

31%

76%

24%

Pre Intervention Post Intervention

Intervention

Control

Results: Comparing Pre to Post Intervention Prevalence of TT

96%

4%

91%

9%

90%

10%

92%

8%

Pre Intervention Post Intervention

Intervention

Control

Results: Comparing Pre to Post Intervention Prevalence of Barriers to Eye Care Service

UtilizationS. Barrier

No (%). reported Yes Difference 95% CI p

Pre Post

1 I didn't feel a problem 77 (87.5) 104 (70.7) 16.80% (6.71 - 26.89) 0.0051

2 Fear of Surgery 78 (90.7) 97 (66.4) 24.30% (14.48 - 34.12) 0.0001

3 Fear of Surgical Outcome 78 (90.7) 83 (63.8) 26.90% (16.61 - 37.19) < 0.0001

4 I am too Old 75 (87.2) 59 (51.8) 35.40% (23.82 - 46.98) < 0.0001

5 Fear of Bad treatment at hospital 59 (68.6) 44 (41.1) 27.50% (13.97 - 41.03) 0.0003

6 Distance to hospital is too long 62 (72.9) 52 (48.1) 24.80% (11.46 - 38.14) 0.0009

7 Expenses of surgery are too much 76 (89.4) 66 (54.5) 34.90% (23.87 - 45.93) < 0.0001

8 No one to accompany me to hospital 47 (56) 42 (40) 16.00% (1.8 - 30.2) 0.041

9 I couldn't quit work to go 36 (42.4) 44 (42.3) 0.10% (-14.06 - 14.26) 0.8933

10 No one to take care of family and children 32 (37.6) 25 (30.1) 7.50% (-6.76 to 21.76) 0.3877

Results: Comparing Pre to Post Intervention Prevalence of Female Specific Barriers to Eye Care

Service Utilization

S. Barrier

Reported Yes, No (%). Differenc

e 95% CI p

Pre Post

1 I didn't feel a problem 58 (86.6) 69 (68.3) 17.60% 5.44 to 29.76 0.015

2 Fear of Surgery 60 (90.9) 65 (64.4) 26.50% 14.87 to 38.13 0.0002

3 Fear of Surgical Outcome 62 (93.9) 57 (60.6) 33.30% 21.86 to 44.74 < 0.0001

4 I am too Old 56 (84.8) 39 (47.6) 37.20% 23.35 to 51.05 < 0.0001

5 Fear of Bad treatment at hospital 39 (70.9) 32 (39) 31.90% 15.91 to 47.89 0.0005

6 Distance to hospital is too long 48 (73.8) 38 (46.9) 26.90% 11.66 to 42.14 0.0018

7 Expenses of surgery is too much 60 (90.9) 43 (49.4) 41.50% 28.91 to 54.09 < 0.0001

8 No one to accompany me to hospital 35 (53.8) 29 (35.4) 18.40% 2.46 to 34.34 0.0387

9 I couldn't quit work to go 29 (43.9) 29 (38.2) 5.70% -10.51 to 21.91 0.6044

10 No one to take care of family and children 25 (37.9) 16 (26.2) 11.70% -4.39 to 27.79 0.2228

Results: Comparing Pre to Post Intervention Surgery Uptake

2002 2003 2004 2005 2006 2007 20080

50

100

150

200

250

300

350

400

450

500

Cataract Surgery Uptake

Male Female

2002 2003 2004 2005 2006 2007 20080

50

100

150

200

250

300

350

400TT Surgery Uptake

Male Female

Important Limitations

• Lack of well trained local cadres.• Considerable percentage of errors in screening.• Difficulty to change perceptions, behaves and norms.• Lack of equipment at local hospital.• Community mistrust of local providers.• Difficulty to dissolve persistent barriers. • Inflexibility of some MoH bylaws.• Inability to calculate exact figures for comparisons.• Percentage of error in relating the improvement in

service uptake to the intervention.• Degree of precision in calculating accurate win rates.• Community expectations exceeded the program

capacity.

Important Conclusions and Recommendations:• Interventions to control blindness should be integrated to cover

different aspects.

• Major avoidable causes should be prioritized then Targeted.

• A pre intervention community assessment should include:– Current situation analysis.– Understanding community in terms of perceptions and barriers.

• Community health education is a quite successful tool.

• Community volunteers and area residents are the best candidate to deliver such messages.

• Using program logic models adds a lot of value in planning and evaluation processes.

Important Conclusions and Recommendations contin’d:

• Conduct of pre and post intervention assessments helps in evaluation of the model and its components.

• Capacity building of local providers enables absorption of the increase in demand and re-build confidence.

• Participatory development approach that engages the community would guarantee sustainability.

• Gender sensitive approach accelerates the prevention and control processes.

• Sustainability of results should be incorporated in the plan a priori.

So, what’s next

• Encourage developing countries to adopt and implement gender sensitive interventions.

• Widening the range of national and international collaborators (ex.

Including other ministries; education, scientific research, water and sanitation, etc.

• Research to develop and document more action oriented research for prevention of blindness.

• Incorporation of prevention of blindness activities into primary health care activities.

• Paying special attention to training and capacity building research.

Funders and Collaborates

• Funders & Supporters:– The Canadian Institute for Health

Research (CIHR-IGH). Canada.– British Columbia Centre for

Epidemiologic and International Ophthalmology (BC-EIO). Canada.

– Al Noor Magrabi Foundation. Egypt.–Magrabi Eye Care Group. Egypt.

Thank you for y

our kind

attention