Women are almost twice as likely as men to require surgery to treat trachomatous trichiasis (TT), the blinding stage of trachoma. Traditional gender roles and norms, such as being more likely to serve as the primary caregivers of children, contribute to women’s higher exposure to trachoma. ​​Additionally, limited health decision-making power, mobility, and other diverse cultural norms can lower women’s uptake of preventive and treatment services, including mass drug administration (MDA) and TT surgery. These services are part of the World Health Organization’s surgery, antibiotics, facial cleanliness, and environmental improvement (SAFE) strategyfor trachoma elimination.

Gender equity and social inclusion (GESI) assessments in trachoma-endemic areas of Ethiopia, Tanzania, and Uganda have found that women face a triple burden by being: 1) vulnerable to abandonment and reduced social standing if affected by TT; 2) financially vulnerable if a spouse has TT; and 3) more likely to serve as the caregiver for a family member affected by trachoma, thereby increasing their exposure to infection.  

Developing locally-led solutions using WI-HER’s iDARE methodology

To identify the context-specific challenges women face in accessing healthcare interventions, WI-HER developed the iDARE™ (Identify, Design, Apply/Assess, Record, Expand) methodology. iDARE enables stakeholders to assess existing systems, identify gaps, barriers, and inequities, and then design, test, and scale local solutions. In particular, iDARE can be applied to identify the groups most vulnerable to being excluded and the barriers they experience to accessing and accepting trachoma interventions.

The iDARE methodology is currently being employed in the United States Agency for International Development (USAID)-funded Act to End NTDs | East program (Act | East). For example, in Oromia region, Ethiopia, WI-HER is working with the Federal Ministry of Health to establish and train district GESI teams, composed of NTD officials and stakeholders involved in NTD service delivery. The district GESI teams recruit community members that did not participate in previous trachoma interventions to identify the causes of missing MDA and develop local solutions to improve access and uptake. Using the iDARE Root Cause Analysis tool, GESI teams can pinpoint specific barriers community members face to participating in interventions and identify women leaders and other influencers in the community who can develop localized solutions to increase the uptake of interventions in future activities. 

The monitoring and evaluation component of the iDARE methodology on Act | East supports understanding between the GESI team, health ministries and implementing partners to determine the impact of contributions of the behavior change team in increasing MDA coverage. If the adapted interventions improve gender equity and social inclusion, the approaches are expanded to other trachoma-endemic areas and integrated in MDA curriculums, social mobilization strategies, and national policies. 

Lessons from trachoma programs in Tanzania and Uganda

The application of iDARE supports governments to improve access for nomadic and indigenous women, who often face increased barriers to trachoma interventions both because of their ethnic group and gender. For example, in Tanzania, many Maasai women have misconceptions and fears about the safety of trachoma medicine and its effect on fertility. 

After applying the iDARE methodology, the Tanzania Ministry of Health through Act | East identified local women leaders, known as Eleigwanani, who could participate in health education sessions and address fears and misconceptions about trachoma in the community, especially relating to concerns about safety of the medicine. The importance of health education was recently highlighted by an Eleigwanani who said “As ladies, we are the ones who change the community. How can we change the community without education?”. Post intervention analysis showed that coverage rates in the intervention villages were 88% compared to the average population coverage of 79.8%.

In Uganda, behavior change teams identified that poor water, sanitation and hygiene (WASH) practices were contributing to the transmission of trachoma in their villages and observed that women were much more likely to manage household hygiene and child facial cleanliness practices than male household members, increasing their exposure to TT. To challenge gender norms in the community and leverage the formal power men have, the behavior change teams designed and implemented a solution in which the male behavior change team members served as role models for other men in the village by taking a more active role in hygiene and sanitation in their own households. Doing so reduces the risk of trachoma within their family, and the unequal burden of caretaking responsibilities and exposure women household members face. Awareness raising via the behavior change teams has been essential to dispel myths and give women a platform to shape community actions.  

Ending the neglect to attain the Sustainable Development Goals: a road map for neglected tropical diseases 2021-2030 calls for continuous, systematic, institutionalized collection, analysis and interpretation of health data disaggregated by gender. However, to achieve gender equity, people-centered approaches need to be built into programs so that women are consulted throughout the program cycle. iDARE is a valuable methodology that national programs can apply to not only monitor gender equity, but also respond to community needs and implement community-led change. This International Women’s Day, we call on global partners to prioritize gender equity integration in trachoma elimination programs. Only then will the global community ensure we ‘leave no one behind’ in our ambition to reach global trachoma elimination by 2030. 

This blog was written by: 

• Dany Chhan, Senior Associate, WI-HER

• Claire Karlsson, Program Manager, WI-HER

• Avani Duggaraju, Senior Associate, WI-HER

• Amy Veinoglou, Program Manager, RTI International

• Jeremiah Ngondi, Senior NTD Advisor, RTI International

• Tim Jesudason, International Coalition for Trachoma Control