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Improving women’s ocular health hinges on education, awareness
In both industrialized and developing nations, women have higher rates of blindness than men for different reasons.
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Past articles in this series have focused on diseases that disproportionately affect women and their eyes, but some factors that greatly affect female ocular health are not biological, but social and economical.
“We’re working at promoting this new level of awareness that two out of three blind people are women,” Suzanne Gilbert, PhD, MPH, told Ocular Surgery News. “When people look out at the waiting room in the hospital or outside the surgical theater, they might see it’s about 50-50 men and women, but we have to know that’s just not enough.”
The financial and cultural status of women in developing and industrialized nations greatly affects their education and access to health care, especially ocular care.
In industrialized countries, women have access and education and are more likely to report their problems, but their longer life expectancy puts them at risk for age-related diseases. Even when age-adjusted, there are still more women with visual deficiencies.
Women in developing nations are considered to be lower on the social scale and, therefore, have less financial resources and are often deemed less important than their male counterparts. Their limited knowledge of health care puts them at a disadvantage in terms of ocular care.
In both cases, education and awareness among ophthalmologists and women themselves would lay the foundation for improving women’s ocular health.
“An eye program that teaches women proportional to their need in the community is probably also reaching other vulnerable members of the community,” Dr. Gilbert said, pointing to women’s traditional role of caretaker to children and elderly family members.
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Images: Lewallen S |
Industrialized nations
Although women in industrialized nations are more independent than those in developing nations and more likely to report health problems than men, they are still more affected by ocular problems and more likely to go blind.
Susan Lewallen, MD, reviewed the literature regarding female blindness in industrialized nations and said the cause for increased blindness among these women is still somewhat of a mystery.
In her study, she pointed to greater female life expectancy, but also said women are altogether more affected by eye disease.
For example, she told OSN in an e-mail interview: “AMD is the major cause of visual loss, and the increased longevity of women means more women are affected.”
She added that it is possible that there are differences in survival between visually impaired women compared with men that contribute to excess blindness in women, but this has not been properly studied.
“Most blindness occurs in the elderly in industrialized countries,” Dr. Lewallen said. “In surveys, the pooling of data from the very elderly makes it difficult to determine the precise contribution of female longevity to excess blindness, but this is probably the key factor.”
Laura L. Hansen, PhD, studies the economics of situations such as these and spoke about the obstacles that women face economically, even in industrialized nations.
“There are more female heads of household than anyone else living in poverty,” she said. “It’s easy enough to do the math, when you think about our divorce rates and how many women bear children out of wedlock, to understand how many, not only women but [also] their children, are living in poverty.”
Dr. Hansen said women are often underemployed and therefore have inadequate or no insurance, which affects their health and ocular health. In addition, she said many people do not value ocular health and do not pursue it actively.
OSN Practice Management Section Editor John B. Pinto said he hoped that women would be comfortable coming to appointments and asking questions in “overwhelmingly” female-based ophthalmic practices.
“It’s a well-recognized phenomenon that women make about 70% of the health care purchasing decisions in the country,” he said. “Not only are they making decisions for themselves, but quite commonly for their entire family.”
Developing nations
In developing nations, there are more reasons, ranging from economic to social, that affect women’s ocular health.
“Less chance of education for girls and women, less control over how household money is spent, less ability to travel out of local community to seek eye care, all contribute” to the lack of coverage for these women, Dr. Lewallen said.
“We have a lot of dynamics, power dynamics, deferential economic dynamics. We often will have the cataract blind woman who says, ‘Yes, I know I could be operated on, but I’d rather have the household put that same effort into taking care of the grandchild,’” Dr. Gilbert said. “Obviously, that’s incredibly role-appropriate and culturally appropriate, but at the same time, we need to find a way to make sure she gets the help she needs, too.”
This second-class mentality contributes to the lack of treatment among women in these countries, compounding economic and other social factors.
“In poor countries, good vision is not always valued as highly for elderly women as for elderly men and, in the poorest places, both sexes often adjust gradually to cataract blindness and learn to live with it,” Dr. Lewallen said.
Education of men and women is necessary to increase the uptake of eye care services by women.
“Women are less aware of the opportunity of surgery and less likely to use it, but that is simply a symptom of a much more comprehensive, complex set of issues, and they have to do with women being sidelined in so many aspects of their culture and their society,” Dr. Gilbert said. “A lot of the counseling that goes on in eye hospitals, to encourage the family to allow the woman to have surgery, is geared toward the son or the husband because they may be very active decision-makers as to the fate of her getting surgery or not.”
Drs. Gilbert and Lewallen, who both have experience working with women in developing nations, agreed that the biggest factor in women’s ocular health is the access they have to treatment.
“Getting [women] in the door is the challenge,” Dr. Gilbert said. “The single most important thing is for programs to consciously make themselves user-friendly.”
She pointed to physical location and financial accessibility as hurdles to overcome for most women. The closer to the homestead and the less expensive eye care is, the more likely women will be to pursue eye care procedures, Dr. Gilbert said.
This financial hurdle can also put women at risk for receiving outdated procedures, she said. Many eye care facilities, even those that volunteer their time and work, require payment for cataract procedures beyond standard extraction, such as IOL implantation.
“If an eye care program provides the [IOL] for only the cataract patient who can pay for service, and if women are less likely to be among the paying patients, then they’re less likely to get the sight-correcting lens,” Dr. Gilbert said.
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Improving the situation
If physicians, researchers and women work together, the experts said they believe that there could be improvement in female blindness.
“Change starts with awareness,” Dr. Lewallen said. “Be aware that there is more blindness in women than in men, and try to understand the roots of the problem.”
In many developing countries, she said, patients do not come forth for treatment unless there are major efforts made at the community level.
“Without efforts at this level, to educate patients about what can be done to cure blindness and help them get to services, many will sit untreated in villages until they die,” Dr. Lewallen said. “Meanwhile, many ophthalmologists only do small numbers of cataract operations each year, sitting in empty clinics or theaters waiting for patients.”
She suggested that programs could be developed to bridge this gap and provide mechanisms to facilitate the connection between physicians and patients.
These bridges are formed through the education of physicians and patients and an implementation of this newfound awareness in daily practice.
“Everywhere in the world, regardless of gender, blind people have a low awareness of eye care services. They have a low recognition that what they have can be corrected,” Dr. Gilbert said. “When we can pierce through these, essentially, myths by providing good information that reaches women, we can be certain it’s reaching men.”
Outside of awareness about eye care, Dr. Gilbert said many studies have shown that a family’s health can be improved through the improvement of the mother’s literacy.
“When we say literacy, we’re thinking in terms of the whole complex women’s empowerment, women’s development and working with the existing women’s rights organizations that are being developed,” she said. “They can become more educated and become better case finders for people who would benefit from more timely eye services.”
Mr. Pinto said physicians in industrialized nations should also be more aware of how daily interactions with women affect their comfort.
“Still, to this day, the majority of decisions about a practice and how it’s run are made by the male owners, while the majority of the customers are female,” he said. “Make sure that you’re allowing your staff to have an outsized role in things such as the access, communication or décor of the practice. Look at your practice from the perspective of the average female patient, and if you feel you’re not good at that, ask the patients themselves or your female staff members.”
Dr. Lewallen said this mentality can be put to work by simply: “Treating women, especially elderly women, with the same respect and courtesy that all patients deserve.”
Dr. Hansen further suggested that the problem also exists in the research done on ocular diseases and other health problems.
“It’s getting better, but the type of research that’s being done is male- oriented research. What they do is impose a male model on the female body, and we’re just touching the surface of what’s different between men and women biologically,” she said. “We need more researchers – males and females – who are interested in women’s health in general.”
Dr. Gilbert said if ophthalmologists in industrialized and developing nations make their services more user-friendly toward women, they will be helping the entire population.
“The women are the canary in the mine. They’re a good indicator population,” she said. “In our experience, if a community-oriented eye care program is reaching the appropriate proportion of women, then they’re probably doing a good job of reaching the entire community.”
In industrialized nations, Dr. Hansen said women must stand up for themselves to improve their own situation.
“If we’re talking about women’s ocular health, women are going to have to mobilize, as in the case of other successful campaigns such as breast cancer awareness,” she said. “Men are not going to do this. It’s going to have to be women mobilizing.”
For more information:
- Suzanne Gilbert, PhD, MPH, is the director of the Center for Innovation Eye Care and can be reached at the Seva Foundation, 1786 Fifth St., Berkeley, CA 94710; 510-845-7382; fax: 510-845-7410; e-mail: suzgilbert@earthlink.net.
- Susan Lewallen, MD, is co-director of the Kilimanjaro Center for Community Ophthalmology and can be reached at KCCO/Tumaini University, P.O. Box 2254, Moshi, Tanzania; 255-27-2753547; fax: 255-27-2753598; e-mail: slewallen@kcco.net.
- Laura L. Hansen, PhD, can be reached at the Department of Sociology, University of Massachusetts Boston, 100 Morrissey Blvd., Boston, MA 02125-3393; 617-287-6261; e-mail: laura.hansen@umb.edu.
- OSN Practice Management Section Editor John B. Pinto can be reached at J. Pinto & Associates, 1576 Willow St., San Diego, CA 92106; 619-223-2233; fax: 619-223-2253; e-mail: pintoinc@aol.com; Web site: www.pintoinc.com.
- Katrina Altersitz is an OSN Staff Writer who covers all aspects of ophthalmology.