Question & problem
Globally, the World Health Organization estimates that 2.2 billion people have a near or distance vision impairment and that 50% of these cases could have been prevented through multiple strategies and measures. According to WHO Afro, visual impairment is a major public health problem in African countries affecting about 26.3 million people and the principal causes are trachoma, cataracts, age-related macular degeneration, glaucoma, diabetic retinopathy, corneal opacity and uncorrected refractive error. The 2019 Global burden of disease report supported by studies showed that visual impairment is higher among adults especially older women and 90% of cases are centered in LMICs (Bourne et al., 2021). Visual impairment affects people’s quality of life, exacerbates poverty, increases risk of mortality, and negatively impacts on individuals’ independence and mental health (Banks & Polack, 2014; Kuper et al., 2019). If no steps are taken, this will derail African countries progress towards the Sustainable Development Goals, especially Goal 3 ‘Good Health and Well-Being’ (as vision has a significant impact on both) as well as the Africa Agenda 2063 which aims to address the continent’s specific development challenges. This evidence brief aims to bring out effective strategies informed by research that can prevent visual impairment among older people in Africa.
Recommendations
Key recommendation
Action
Countries’ Ministries of Health to conduct Mass media campaigns via community radios, televisions, billboards, and community gatherings, making women as peer educators to mobilise other women conducting door to door community campaigns, involve women in decision making when planning and establishing eye care programmes and outreach sites for eye services
Key recommendation
Action
To conduct Knowledge Attitude and practice studies regarding utilization of eye health services, carry out RAABS in order to generate evidence for burden of visual impairment among the older population and to address gender-induced barriers to access and uptake of eye health services by bringing women and eye health services together, counselling family members to support women in seeking eye health services including providing company and to involve men as active partners in addressing gender imbalance. Advocating with men to allow and support women to access eye health services and involving traditional leaders as custodians of culture and tradition to support gender balance and women empowerment as agents of change and role models
Key recommendation
Action
Targeting young girls and women through antenatal care, immunization and vitamin A supplement, school screening, refraction and trichiasis surgery have improved vision outcomes for women. Cause-specific treatment and preventive interventions like early diagnosis, treatment and systematic follow up of diabetic patients for elimination of diabetic retinopathy and glaucoma screening, affordable cataract surgery services and provision of affordable or free spectacles will go a long way in improving vision among older women.
Key recommendation
Action
Integrating eye care programmes within primary health systems to promote accessibility, availability, affordability, and acceptability in line with the Alma declaration (1978), Astana declaration (2018) and WHO concept of Universal Health Coverage. African governments to subsidize or make eye health services free at all primary and secondary level care to increase access, uptake, and affordability in line with WHO Universal Eye Health Global Action plan 2014–2019.
Key recommendation
Action
Human resources for health - Train, equip and distribute eye health personnel including ophthalmologists, optometrists, and ophthalmic nurses.
Challenges
Challenge #1: Older people especially women in Africa have more barriers in accessing eye health services especially those in rural communities compared to men.
- About 80% of visual impairment cases are above 50 years and 55% of those are women. Socio-cultural factors contributing towards visual impairment risk included family responsibilities like tilling land, fetching firewood. Women’s health is generally not prioritized and lack of childcare leaves women with little time to access health services to resolve issues in their early stages. Women also have higher life expectancy and are therefore more likely to experience visual impairments associated with old age like macular degeneration.
- Economic factors include older people, especially women to be less financially stable and having little influence and control over family budgets for help-seeking, especially in most rural settings. Limited freedom of movement due to dependence, transport cost, cost of services and distance exacerbate the situation of older people getting eye care screening and treatment especially women. Late detection delays treatment and prognosis so it is sobering to consider that the incidence of cataracts can be reduced by about 12.5% if women get the same cataract surgical coverage as men in African contexts (Lewallen & Courtright, 2001).
Challenge #2: Stigma and fear among women to openly access eye health services like cataracts surgery.
- Most women in African countries are fearful on the impact of visual impairment on their status in the family and community therefore can downplay the impact of visual impairment (Lewallen & Courtright, 2009). This also affects how they perceive the risk of developing these conditions as well as informed decisions around access, demand, and information about utilizing eye care services in some parts of Africa.
Challenge #3: Dearth of training opportunities for optometrists and other eye healthcare personnel in Africa
- Only 16 out of 27 African countries surveyed (59%), have optometry training schools leaving 11 without any form of training for eye health, leaving an average ratio of 1 optometrist to 100 996 individuals requiring eye health care.
- An estimated two countries; South Africa and Nigeria contribute 83% of total optometrists in Africa leaving other 25 countries to share 17%.
Challenge #4: Eye care services are generally unaffordable and out of reach for many people in Africa
- Eye healthcare services like refraction, cataract surgery and screening are generally not available in most primary health facilities in most African countries. These types of specialist eye care services are mostly available at secondary level, centred in urban sites and the cost of travelling and distance adds to the total cost of these services for service users.
- A stark 27 out of 48 countries in Africa have populations that rely on out-of-pocket payments. In countries with health insurance, it only serves an average of 15% of the population which is not enough to address the burden of eye health concerns in the populations.
Challenge #5: Patriarchal societies and lack of political will
- Making services available alone is not adequate and it requires addressing deep rooted patriarchal beliefs and a whole system approach including women empowerment and having a voice in decision making in the family so that they can travel to access services and shared responsibilities in household chores.
Finding the answers
We conducted a review of reviews, WHO publications including the draft action plan for the prevention of avoidable blindness and visual impairment 2014–2019 and examining systematic, narrative, and other types of evidence on the most effective strategies for preventing visual impairment among older women in Africa. A total of 18 papers were reviewed with 9 publications focusing on Africa, 2 publications focused broadly on developing countries, 1 publication on Asia and 5 publications focused on high income countries including 3 publications from the Lancet. In recommending the strategies, we noted that some of the effective strategies from high income countries publications are applicable to African countries since some causes are similar like cataracts, age-related macular degeneration, glaucoma, and refractive errors. However, some recommended strategies from high income countries need to be customized to adequately apply and respond to the context of African countries while some recommended strategies from broadly developing countries fit within the African context.
Recommendations & actions
Key recommendation
Action
Countries’ Ministries of Health to conduct Mass media campaigns via community radios, televisions, billboards, and community gatherings, making women as peer educators to mobilise other women conducting door to door community campaigns, involve women in decision making when planning and establishing eye care programmes and outreach sites for eye services
Key recommendation
Action
To conduct Knowledge Attitude and practice studies regarding utilization of eye health services, carry out RAABS in order to generate evidence for burden of visual impairment among the older population and to address gender-induced barriers to access and uptake of eye health services by bringing women and eye health services together, counselling family members to support women in seeking eye health services including providing company and to involve men as active partners in addressing gender imbalance. Advocating with men to allow and support women to access eye health services and involving traditional leaders as custodians of culture and tradition to support gender balance and women empowerment as agents of change and role models
Key recommendation
Action
Targeting young girls and women through antenatal care, immunization and vitamin A supplement, school screening, refraction and trichiasis surgery have improved vision outcomes for women. Cause-specific treatment and preventive interventions like early diagnosis, treatment and systematic follow up of diabetic patients for elimination of diabetic retinopathy and glaucoma screening, affordable cataract surgery services and provision of affordable or free spectacles will go a long way in improving vision among older women.
Key recommendation
Action
Integrating eye care programmes within primary health systems to promote accessibility, availability, affordability, and acceptability in line with the Alma declaration (1978), Astana declaration (2018) and WHO concept of Universal Health Coverage. African governments to subsidize or make eye health services free at all primary and secondary level care to increase access, uptake, and affordability in line with WHO Universal Eye Health Global Action plan 2014–2019.
Key recommendation
Action
Human resources for health - Train, equip and distribute eye health personnel including ophthalmologists, optometrists, and ophthalmic nurses.
Policy priorities
National governments to address social determinants of health-related factors like deep rooted cultural, inequalities, gender imbalance, distribution of health centres, and societal imbalances that increase barriers to accessing eye health services for older people including women. It requires holistic approach in addressing other barriers like cost, distance, transport, and stigma associated with accessing eye health services. Development partners like NGOs and advocacy groups to advocate with Ministries of Health, Ministries for Women, and related departments to address deep rooted gender imbalances. Ministries of Health and Higher education should establish and or increasing intakes for training of eye health specialists and personnel like optometrists.
Conclusion
Older people have higher prevalence of visual impairment with women accounting for 55% owing to a variety of factors including longevity, diabetic retinopathy, gender imbalance, limited access to finances and women’s traditional roles and duties in the community. In this brief, we put forward strategies that may go a long way in addressing the barriers to accessibility, affordability, availability, and acceptability of eye care services. Other strategies focused on what governments can do in terms of improving eye infrastructure and equipment, research, training, awareness and addressing social determinants of health like poverty and inequality.
Gaps & research needs
This evidence brief was prepared with literature from systematic reviews, lancet publications, WHO policy documents and other peer reviewed publications, however more publications specific to Africa are needed. To reduce researcher and selection bias, article screening, data extraction and scoring should not be done by a single individual. African countries vary in terms of development index, poverty, and investments in healthcare, and it will be appropriate for future studies to group the countries by geographic location, level of development and income per capita because the structural, economic, and other factors are not homogenous in all African countries. Further research on visual impairment among older women to explore more on the gender dynamics in relation to visual impairment.
Acknowledgements
Peer Review: This brief has been peer reviewed by Geoffrey Wabulembo, Medical Eye Health Director of Light for the World and Onaiza Qureshi, Knowledge Exchange Officer, Disability Evidence Portal.
Publication details: © International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, March 2022.
Suggested citation: Enock Musungwini. Evidence Brief: What are the most effective strategies for preventing visual impairment among older people in Africa? Disability Evidence Portal, 2022.
Disclaimer: The views expressed in this publication are those of the author/s and should not be attributed to Disability Evidence Portal and/or its funders.