Gender equity in the global trachoma program: understanding intersectionality to achieve vision for all

07 Mar 2023 
 A woman receives Zithromax during a trachoma treatment campaign in Mozambique. Photo credit: RTI International/Damien Schumann

Women are almost twice as likely than men to require surgery to correct in-turned eyelashes, known as trachomatous trichiasis, which results from repeated infections of trachoma. These repeated infections occur, in part, from women's repeated exposure to the causative bacteria Chlamydia trachomatis due to their typical role within the home as caregivers. Increased exposure is exacerbated by barriers to quality health care and lower uptake of services, which increase health inequalities and threaten progress towards universal health coverage. 

Experiences from the global trachoma program provide insights into a range of intersectional aspects of gender inequity, including cultural, ethnic, disability, social and economic barriers to healthcare. In several national trachoma programs, the identification of gender inequities has facilitated the development of gender sensitive approaches to accelerate the elimination of trachoma as a public health problem, while advancing progress towards Sustainable Development Goal 5: Gender Equality. 

In Uganda, Kenya and Tanzania, where nomadic communities are at risk of trachoma, men frequently travel across borders to care for their livestock, while women pursue agricultural activities and care for their children. As child rearing is associated with transmission of Chlamydia trachomatis, this puts women at an increased risk of infection.  

Women from nomadic communities, including the Maasai and Turkana, two distinct ethnic groups in Eastern Africa, are often mistrustful of trachoma interventions, and more broadly modern medicine, often favoring traditional medicines. A major cause of mistrust is related to concerns that western medicine can reduce fertility and cause harm to pregnant women. This is a particular challenge in Maasai and Turkana cultures, where a woman’s position in society is strongly associated with their ability to have children, and infertility can severely impact a woman’s prospect of marriage and financial security.  

To improve uptake of interventions, health ministries of Uganda, Kenya and Tanzania collaborate through the Eastern Africa Cross Border Partnership to develop tailored messaging and education campaigns that address cultural beliefs that can prevent women from benefiting from trachoma interventions. Mass media campaigns target women specifically through radio messages and community health workers are trained to speak with women directly and alleviate concerns about the impact of medicines on fertility. 

Similarly, the United States Agency for International Development (USAID) Act to End NTDs | East (Act | East) program applies a gender equity and social inclusion approach to determine who is being missed with neglected tropical disease (NTD) services and supporting governments and local communities to develop solutions to increase uptake. In Tanzania, Act | East is working directly with local women leaders, known as Eleigwanani, to educate and encourage women in their communities to take the medicines. Simultaneously, traditional Maasai male leaders are also tasked with educating men in the community about the benefits of trachoma interventions, to shape household healthcare decisions often made by male heads of household on behalf of Maasai women.  

Research conducted by Light for the World in Burkina Faso, Ethiopia and Mozambique also highlights a range of barriers for women accessing interventions. The 18-month pilot project, called Equitable eye care for all! ran from July 2021 – December 2022, with the aim to identify barriers to eye care, including trachoma, and best practices to improve gender equity that would be replicable across the health sector.   

The project (available in EnglishFrench and Portuguese) showed that overall, women and girls appeared less likely to access eye health services, and when they did have better access to eye consultations, women still had fewer surgeries than men, suggesting gender inequity in accessing healthcare between consultations and treatment. The reasons for lower access and uptake can include a range of issues related to cost, access and perceptions. This can include the cost of the interventions, the cost of transport to reach intervention sites, or the cost of taking time off from work in order to access the intervention. When and how interventions are offered such as the time of day can impact access for women, especially those with disabilities. Misconceptions about the dangers of interventions and fear of social stigma around disclosing health status, particularly relating to any disabilities can also impact access and uptake.

The study presented 10 lessons to advance universal eye health coverage among women, including:

  1. Partner with community-based organisations to raise awareness.
  2. Regularly train eye health staff about gender equality, especially in rural areas. 
  3. Develop and share gender-sensitive information to promote eye health.
  4. Recruit women as well as men to advocate for gender equality. 
  5. Work with and train community and religious leaders on gender equality. 
  6. Use public spaces to share information and raise awareness. 
  7. Avoid a “first-come, first-serve” approach to providing eye consultations and surgery in rural communities. Women tend to arrive later because they need to attend to household chores in the morning. They also often need to leave early due to caregiving responsibilities. 
  8. Make sure that eye clinics have enough space in their waiting areas and that changing cabins are provided. 
  9. Understand and accommodate the schedules and priorities of potential patients. 
  10. Include an eye health counselor/psycho-social advisor on the eye health team both during outreach and at the hospital. 

Progress to achieve gender equity has been made across the global trachoma elimination program. The use of technology to map trachoma, including the collection of gender-disaggregated data, has enabled programs to be more targeted in their approaches, and in 2021, 69% of people who received surgical services were women in the 30 countries that reported gender-disaggregated data. Although this is encouraging, more needs to be done to achieve gender equity in programs – particularly among women within statistically invisible populations to the trachoma program, including but not limited to nomadic, indigenous communities, and women with disabilities – who will often require tailored approaches to ensure that interventions are accessible and acceptable. 

Ending the neglect to attain the Sustainable Development Goals: a road map for neglected tropical diseases 2021-2030 calls for continuous, systematic, institutionalized collection, analysis and interpretation of health data disaggregated by age, gender and location for informed decision-making. However, to achieve gender equity, it will be important to go further than collecting gender disaggregated data, and ensure that we address the intersections between gender, ethnicity, socioeconomic status and disability.  

Facilitating partnership between affected communities, researchers, implementing partners, and health ministries, to identify and answer important operational and social research questions around the causes of gender inequity in trachoma programs will improve understanding and strengthen programs, while also providing essential evidence to health systems integrating trachoma interventions.

● Jennifer Pitter-López – Light for the World
● Mathilde Umuraza – Light for the World
● Claire Karlsson – WI-HER
● Raphael Opon - Ministry of Health Uganda
● Tim Jesudason – International Coalition for Trachoma Control