Module 1: Unique Barriers to Health Care for Women

Introduction

Why don't people seek health care services when in need and when care is available? The answer to this question is multifold, and it is important to note that lack of awareness about treatment availability and benefits is not the primary issue. (1) Rather, patients face a variety of barriers that combine to prevent them from seeking proper medical attention. The barriers to care include cost, fear of doctors and treatment, cultural beliefs about fatalism, and lack of transportation, among others.

While many people in low- and middle-income countries face these challenges, women disproportionately bear the burden of health inequalities across the globe and are presented with unique barriers to accessing medical care. For example, women and children are disproportionately affected by transportation barriers, which may arise in the form of geographical isolation, lack of public transportation, or lack of funds to purchase their own mode of transportation.

Examples from Eye Care

Although blindness in the developing world is oftentimes curable, most patients do not receive medical attention. One recent study found that “over two thirds of adults over age 40 in a rural Indian population with low vision secondary to cataracts, glaucoma, and refractive error had never sought eye care,”(2) while another study showed that “90 % of the people seeking eye care in poverty-stricken areas in Sri Lanka had similarly had no previous eye care.” (3)

Researchers have found that approximately two out of every three blind people in the world are women; most of these women are over 50 years of age, and ninety percent live in poverty. (4) This ratio was found in most population-based blindness prevalence surveys from economically poorer countries as well as from modernized western societies. In no instances did biological differences explain these gender disparities.

Not only are women more likely to have higher rates of blindness, they are also less likely to obtain proper eye care. “Women of all ages (including children) are more frequently exposed to causative factors, such as infectious diseases and malnutrition, and utilize eye care services less frequently than men.” (5) Several studies have documented such disparities. For example, women account for 67% of all individuals with visual problems and were found to utilize eye care services 40% less than men. (6)(7)(8) In Central Ethiopia, women comprise 59% of blind individuals and 70% of people with low vision. The difference in gender distribution and low vision is statistically significant in all age groups. (9) In addition, females in South India are less likely to have surgery for cataracts, yet the cataract blindness burden is higher for women. (10)

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 underlying these proximate factors are the ultimate causes of gender inequality. Socially embedded constructs of masculinity, power differentials, and social status are all fundamental factors that manifest 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. (11)(12) Proximate reasons cited for this difference include lower literacy rates among women (13) and the fact that “poor rural women often have less disposable income, or control of finances, than men.”(14) 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.” (15) 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. (16)

Another reason why women may not seek corrective surgeries is the expectation that they 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.

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 Global South. In order to reduce gender disparities, the ways in which social status impacts health must be understood. The inferior social status of women may increase their susceptibility to disease through a mechanism of dependency, vulnerability, and lack of opportunity. These social realities are the result of larger power differentials embedded within the community. A low social status means that women often do not have the same privileges and “rights” as men. In such an atmosphere, women may have less of an ability to assert themselves, 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 raised 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 walk to a health facility. (17) Similarly, a woman’s financial access to care may depend 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 a 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.” (18)

Conclusion

Within the fields of epidemiology, anthropology, sociology, and public health, the unique problems that women face are familiar and well-conceptualized. Yet despite the 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. In other words, understanding about the issue has not translated into a solution. The reality that women in low- and middle-income countries are not only victimized by poor health, but also by societal conditions that can make it impossible for women 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.” (19)

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Footnotes

(1) Donoghue, M. “People Who Don’t Use Eye Services: ‘Making the Invisible Visible.’” Journal of Community Eye Health. 12.31 (1999): 36-38. Accessed on 8 January 2009.

(2) 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. Accessed on 8 January 2009.

(3) Holden, B.A. “Blindness and Poverty: A Tragic Combination.” Clinical and Experimental Optometry. 90.6 (2007): 401-403. Accessed on 8 January 2009. .

(4) 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.

(5) Seva Canada Society, and Seva Foundation. Gender and Blindness: Initiatives to Address Inequity. Rep. 2008. Web. 6 Aug. 2009.

(6) 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.

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

(8) 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.

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

(10) 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.

(11) Lewallen, S. and 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.

(12) 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. Accessed on 8 January 2009.

(13) Ibid.

(14) Lewallen, S. and 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.

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

(16) 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.

(17) Seva Canada Society, and Seva Foundation. Gender and Blindness: Initiatives to Address Inequity. Rep. 2008. Web. 6 Aug. 2009.

(18) Ibid.

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