Trachoma, the world’s leading infectious cause of blindness, disproportionately affects women. Research suggests women are twice as likely to require surgery to treat trachomatous trichiasis, the late blinding stage of trachoma, than men. In part, this is due to increased exposure to Chlamydia trachomatous, the causative bacteria of trachoma, from gender-related roles, such as childminding. Gender inequality is exacerbated by inequitable access to health services in many settings.
In East Africa, trachoma remains a public health problem in areas inhabited by the Maasai. In 2016 the prevalence of trachoma in predominantly Maasai districts in Northern Tanzania was estimated to be more than 50%. Women living in these communities often faced increased disadvantages accessing health services due to the remoteness of their communities, in addition to social, economic, and environmental barriers. For example, a recent study looking at MDA in a Maasai community in Tanzania found that pregnant women often accepted the antibiotic but did not swallow the drug due to their norms and beliefs.
To improve knowledge and to empower Maasai women as health educators in their communities, a recent project assessed the use of Photovoice - a method that provides participants with cameras to visually document a specified topic in order to improve knowledge, reflection and stimulate dialog on an issue and facilitate social change.
The project included a workshop providing trachoma education to Maasai women, who were tasked with sharing that information back with their communities. Towards the end of the workshop, women were given disposable cameras to document their efforts as trachoma ambassadors. They were taught how to use the cameras, what types of images they can capture, and the ethics of photography. Women were asked to photograph people, activities and things that can convey their efforts as trachoma elimination ambassadors including successes and challenges.
What was taught?
During the workshop, women were taught about the causes of trachoma, its transmission, symptoms, prevention and treatments. Stuffed sorbens (flies) were used to show transmission of chlamydia trachomatis from flies to eyes. Workshop facilitators used baby powder, representing chlamydia trachomatis, around the eyes of women to show how easily the disease can be transmitted through flies or other items. This highlighted the importance of facial cleanliness to prevent transmission. A storytelling session was also held to convey lessons around trachoma infection and treatment. This was followed by a short video by The END Fund and Sightsavers, “Leaky Tin: A Simple Solution”, which was translated into Maasai language to show a simple and effective way to wash faces and hands using minimal amounts of water.
What we found
When photographs were reviewed, the most commonly shared photos were of children either washing their faces or displaying clean faces with no flies. Women shared photos of individuals cleaning up trash or human and animal faeces, cleaning clothes and displays of ‘leaky tins’ at their enkang (homestead). Some women shared photos of themselves conducting meetings with other women in their village to educate them on trachoma. However, very few women shared photos of challenges but of those that did, the photos showed traditional practices of treating trachoma-like symptoms and of animal carcases. The workshop only mentioned faeces as a source of flies and despite this, women reasoned that animal carcases were a source of flies. This is a very real source of flies in this community with a lot of carcases of wildlife and donkeys close to their enkang.
Photovoice as a tool for trachoma elimination
Women gained important knowledge about trachoma from the workshop. Photovoice provided a means to share how women transferred knowledge from the workshop to their community and the response from the community. This was evident from the follow-up visit to their homes as well as the photos they shared, particularly those taking action to reduce risk factors in their homes, such as cleaning up animal faeces, erecting leaky tins for hand and face washing and increased face washing for children and adults.
Impact on women
Throughout this project, women felt proud to be selected by male community leaders to take on the responsibility of representing their sub-village and acquiring new knowledge. They felt valued as experts within their community when they disseminated their newly acquired knowledge. Women were agents of change in their community by spreading the trachoma education they received to other women in their communities. Conversations and photographs demonstrated participants effectively stimulated social change.
Access to and use of resources
All women in the intervention reported that it was their first time using a camera. When first given the cameras, they were unsure which way to hold them or what the mechanism was to capture an image. Through demonstrations and practice they proudly improved locating an image, focusing on it, and pressing the shutter-release. The women were being trusted to provide information with cameras which added additional value for them. Through gaining knowledge to control trachoma, women were trusted by husbands to utilize household resources to aid in control measures such as containers for leaky tins, purchasing soap for washing bodies and clothes, and use of limited water for preventive techniques.
Photovoice provided a personalized perspective that researchers or NGOs would not otherwise experience - images inside people’s homes, engaging in social activities, and documenting behaviours that words could not fully capture. It should be considered for future interventions as a communication tool on health issues and to empower women to be ambassadors for health promotion.
The intersection between gender and ethnicity exacerbates challenges for Maasai women to receive the interventions they need to achieve the elimination of trachoma as a public health problem. This intervention demonstrates what can be achieved through the empowerment of women in the community. The global trachoma program has a unique opportunity to improve women’s health while dismantling harmful gender-based practices. Interventions like photovoice should therefore be considered in future programs to ensure that women’s participation is systematic and that trachoma programs maximize their contributions to the achievement of Sustainable Development Goal 5: Gender Equality.