Module 3: Accessing Medical Care: Unique Barriers for Women

Women disproportionately bear the burden of health inequalities across the globe and face unique barriers in accessing medical care. Not only do women have higher rates of blindness, but they are also less likely to obtain proper eye care. Women account for 67% of all individuals with visual problems, adjusted for age, and irrespective of biological attributes. Additionally, women were found to utilize eye care services 40% less than men.(1)(2)(3) In Central Ethiopia, women comprise 59% of the blind population and 70% of people with low vision. The difference in gender distribution and low vision is statistically significant in all age groups.(4)  In addition, females in South India are less likely to have surgery for cataracts, although the cataract blindness burden is higher for women.(5) 

Furthermore, researchers conducted a meta-analysis of population-based prevalence studies and found that approximately two out of every three blind people in the world were women, most of whom were over the age of fifty years, and ninety % lived in poverty.(6) This ratio was found in most population-based blindness prevalence surveys from poorer countries as well as from modernized western societies. In no instances did biological differences explain the gender disparities. Instead, “women of all ages (including children) were more frequently exposed to causative factors, such as infectious diseases and malnutrition, and utilized eye care services less frequently than men”.(7)

Why do these drastic inequalities exist? On the surface, there are proximate factors that contribute to health disparities between men and women, such as lower levels of education, literacy, and socioeconomic status.  Yet behind these factors are the ultimate causes of gender inequality. Socially embedded constructs of masculinity, power differentials, and social status are all fundamental factors that manifest themselves in poor health outcomes for women and constrain their ability to access medical care.

Proximate Factors

As discussed, many studies reveal that women receive eye care at a lower rate than men despite a higher prevalence of eye diseases.(8)(9) Proximate reasons cited for this difference include lower literacy rates among women(10) and the fact that “poor rural women often have less disposable income, or control of finances, than men.”(11)  In fact, “female literacy remains the strongest independent predictor of health service utilization by women themselves and of the overall population, across all socioeconomic levels”.(12)  Public health interventions in Southern India have shown that an indirect investment in female education improves all aspects of health, including an increase in the use of already available health services.(13)

Another reason women may not seek corrective surgery is the expectation that they must stoically persevere through adversity.

One study found "that men were more likely than women to adopt a ‘sick role’. In contrast, women were more likely to continue their routines through ‘adversity’ instead of emphasizing the need for surgery. For example, one of the study’s respondents explained that blindness does not stop her from cooking:

‘When I lit a fire for cooking I recognize it by its heat … I hear the sound when water starts boiling. Then I put flour and the food gets ready. I put the food on the plate and family members serve themselves. (Dodoma-6: Woman: over 75 years old)’(14)

Ultimate Factors

While lower levels of education, literacy, and income are proximate reasons for gender disparities in eye health, the root cause can be traced to the low social status of women in much of the developing world. For example, the inferior status of many women increases their susceptibility to disease through mechanisms of dependency and vulnerability. These social realities are the result of larger power differentials embedded within the community. A patriarchal society combined with an atmosphere of traditionalism can create a social stigma against women, which is often a cultural construct within individual perceptions and social institutions.  A low social status means that women often do not have the same privileges and “rights” as men. In such an atmosphere, women have less of an ability to assert themselves, which is a major impediment to accessing healthcare.

Because of these ultimate and proximate factors, the many barriers that impoverished individuals face in accessing care—such as transportation, money, and stigma—are higher for women.  For example, the amount of time that a woman can spend travelling to get medical care is dependent on her unique social role.  Because women are often the primary caretakers, they must find ways to navigate the obligations of childcare and household duties in order to make time to visit a health facility.(15)  Similarly, a woman’s financial access to care depends not only on household resources, but also on her societal value.  If her husband or relatives decide that it is not worth spending the money, then the woman lacks financial access to care.

“Cultural obstacles to accessing health care are many and powerful. Woman and girls are often sent to cheaper traditional healers rather than Western medical providers. They may be discouraged or forbidden from leaving the house, even for medical care. They may not be allowed to see male health care providers, even if female providers are not available.”(16)

Within the fields of epidemiology, anthropology, sociology, and public health, the unique problems that women face are familiar and well-conceptualized. Yet despite the analytical understanding and academic consensus around the issue of women’s vulnerability to infectious and chronic diseases, the problem remains virtually untouched in the policy world. The reality that women in the developing world are not only victimized by poor health, but also by societal conditions that make it impossible for them to be in control of their health, poses major challenges for policy-makers. In this situation, it seems that the largest impediment to action is complexity. As Bill Gates remarked in a Harvard commencement address, “The barrier to change is not too little caring; it is too much complexity. Yes, inequity has been with us forever, but the new tools we have to cut through complexity have not been with us forever. They are new – they can help us make the most of our caring – and that’s why the future can be different from the past.”(17)

Footnotes

(1) Fouad D, Mousa A, Courtright P. Sociodemographic characteristics associated with blindness in a Nile Delta governorate of Egypt. . 2004;88:614-618.

(2) Gender and blindness educational strategies in Menia Governorate. Canada Fund. Sector Code: 17/35 Reference: 38-7-ARE-1-03/03.

(3) Fouad D, Mousa A, Courtright P. Sociodemographic characteristics associated with blindness in a Nile Delta governorate of Egypt. Br J Ophthalmol . 2004;88:614-618.

(4) Woldeyes A, Adamu Y. Gender differences in adult blindness and low vision, Central Ethiopia. Ethiop Med J. 2008 Jul;46(3):211-8.

(5) Nirmalan PK, Padmavathi A, Thulasiraj RD.Sex inequalities in cataract blindness burden and surgical services in south India.  Br J Ophthalmol. 2003 Jul;87(7):847-9.

(6) Abou-Gareeb I, Lewallen S, Bassett K, Courtright P. Gender and blindness: A meta-analysis of population-based prevalence surveys. Ophthal Epid. 2001;8:39-56.

(7) Shaikh, Alanna. Accessed on 6 August 2009.

(8) Lewallen, S. & Courtright, P. “Gender and use of cataract surgical services in developing countries.” Bulletin of the World Health Organization. 80.4 (2002): 300-303. Accessed on 8 January 2009.

(9) Chang, M.A., Condon, N.G., Baker, S.K., Bloem, M.W., Savage, H. and Sommer, A. “The surgical management of cataract: barriers, best practices, and outcomes.” International Ophthalmology. 28.4 (2008): 247-260.

(10) Ibid.

(11) Lewallen, S. & Courtright, P. “Gender and use of cataract surgical services in developing countries.” Bulletin of the World Health Organization. 80.4 (2002): 300-303.

(12) Courtright P, West SK, Contribution of Sex-linked biology and gender roles to disparities with trachoma. Emerging Infectious Diseases 2004;10:2012-2016.

(13) Nirmalan PK, Padmavathi A, Thulasiraj RD. Sex inequalities in cataract blindness burden and surgical services in south India. Brit J Ophthal. 2003;87:847-849.

(14) Geneau, R., Massae, P., Courtight, P., and Lewallen, S. “Using qualitative methods to understand the determinants of patients’ willingness to pay for cataract surgery: A study in Tanzania.” Social Science & Medicine. 66.3 (2008) 558-568.

(15) Shaikh, Alanna. Accessed on 6 August 2009.

(16) Ibid.

(17) Gates, Bill. Address at Harvard, June 7, 2007. Innovations (2)4:2007.