Interventions to improve gender equity in eye care in low-middle income countries: A systematic review

Author: Mercer GD, Lyons P, Bassett K

Geographical coverage: Ethiopia, Malawi, Nigeria, Tanzania, Bangladesh, India, Nepal, China, and Egypt

Sector: Service delivery

Sub-sector: Access

Equity focus: Not reported

Study population: Studies evaluating interventions that sought to improve access to care for age-related cataract, childhood cataract and trachoma

Review type: Effectiveness review

Quantitative synthesis method: Meta-analysis

Qualitative synthesis method: Levesque’s framework of healthcare access

Background:

Gender is a key determinant of eye health. Worldwide, women bear a disproportionate share of blindness and moderate-to-severe visual impairment, largely because they face greater barriers to accessing eye-care services rather than owing to biological differences. Women are more likely to be affected by cataract, trachoma and uncorrected refractive error, yet surgery rates remain lower among women even when need is greater. Similar inequities are seen in children, reflecting wider structural disadvantages. Interventions that address the specific obstacles women encounter are therefore essential.

Objective:

To synthesise the impact of existing eye-health interventions on gender equity.

Main findings:

Thirteen studies were included—four cluster randomised controlled trials and nine observational studies—all judged to be at serious risk of bias.

• Conditions studied: age-related cataract (5), childhood cataract (2), trachoma (3) and general paediatric eye health (3).
• Settings: seven studies in sub-Saharan Africa (Ethiopia, Malawi, Nigeria and Tanzania), four in South Asia (Bangladesh, India and Nepal) and one each in China and Egypt.

* RR = risk ratio; OR = odds ratio; ROR = ratio of female-to-male odds ratios.

Overall, multi-component, community-based strategies that explicitly address gender-related barriers showed the greatest promise, but evidence quality was uniformly low.

Methodology:

MEDLINE, CENTRAL, Embase and CINAHL were searched to 16 October 2017 for studies from World-Bank-defined low- or middle-income countries reporting interventions intended to improve access to care for cataract or trachoma. Reference lists were hand-searched and experts consulted. Two reviewers independently screened studies; one extracted data, with a second reviewer checking. Risk of bias was assessed using Cochrane tools. Where appropriate, results were pooled with generalised linear mixed-effects models; otherwise a narrative synthesis was structured using Levesque’s access framework. Evidence certainty was judged with GRADE.

Applicability / external validity:

Evidence came mainly from sub-Saharan Africa and South Asia, with none from Latin America and only one study from South-East Asia. High risk of bias, heterogeneous interventions and context-specific barriers limit generalisability. Rigorous, gender-integrated evaluations in diverse settings are required.

Geographic focus:

Sub-Saharan Africa (Ethiopia, Malawi, Nigeria, Tanzania); South Asia (Bangladesh, India, Nepal); China; and Egypt. No geographical limits were imposed.

Summary of quality assessment:

Overall confidence in the review’s conclusion is low. Searches were comprehensive and eligibility criteria were explicit; two reviewers screened studies, and risk of bias was assessed with established tools. However, data extraction by a single reviewer, absence of an excluded-studies list and uniformly serious risk of bias in the included studies weaken reliability.