Initially, the CATCH programme ‘piggybacked’ trachoma programmes, using camps set up to treat people with trichiasis (the most advanced form of trachoma) to identify people with other eye health conditions and provide treatment.
The most common condition found through CATCH has been cataracts, a blinding condition that tends to affect people as they age, yet can be easily treated with a straightforward, sight-restoring operation. As with many eye conditions, cataract disproportionately affects women. Yet in a lot of places, reaching women who need treatment can be challenging.
CATCH finished in March 2019, and over the past four years has restored the sight of more than 21,000 people through cataract operations. It has also generated a wealth of insight that will help inform other eye health programmes – not least about how women and marginalised groups, such as people with disabilities, can be supported to access eye care.
The CATCH programme, funded by UK aid, has restored the sight of more than 21,000 people.About the programme
One of the most successful strategies for helping more women to undergo cataract surgery happened in Malawi. Here, focus group discussions were held during screening camps, which enabled us to hear what women thought of the way the camps were organised, then adapt to better suit their needs. It became apparent that holding camps during the middle of the day wasn’t working as many women wanted to go home to cook for their children at lunchtime. So we began to limit the number of screening sites per day to one or two, holding sessions early in the morning or late in the afternoon to accommodate more women.
In Mozambique, Uganda and Kenya, feedback from the surgical camps reached us via Sightsavers’ staff and implementing partners. Although the main reason these staff were there was more operational in nature, they got to learn about patients’ experiences and the barriers they faced, which proved to be very useful.
For example, in one particularly patriarchal context we proposed using a female surgeon to operate on female patients, because we felt most men would feel more comfortable having a woman operate on female community members. But then we discovered that many of the women in the area were actually less comfortable with this because they thought a female surgeon might not be as competent as a male surgeon. During community meetings we emphasised that female surgeons are just competent as their male colleagues, and the community became more receptive of the services of the surgeon available, irrespective of gender.
Most of the trachoma camps were held in remote areas without hospitals, but cataracts need to be operated on in a sterile environment. Anyone diagnosed with the condition would therefore be referred to the district hospital, which usually has an operating theatre. Over time we realised that if we let people go back home after being diagnosed, many would not return to the district hospital at the agreed time – they may not be able to reach the hospital because of distance, or may be worried about what will happen when they get there.
So, after counselling people so they understood the process and were happy to consent to it, we transported people to the nearest district hospital on the day they were diagnosed, where a surgeon was waiting to operate on them. They would then be taken home within a day or two of their operation.
Yet for some people, even getting to the camps to be diagnosed was difficult, especially for very elderly people or those with disabilities. To address this we enlisted locally trained volunteers to identify people who needed treatment, then we picked them up and brought them to the camp.
A large proportion of the people we were dealing with as part of the CATCH programme were elderly, and many were almost blind, so most of them needed help with everyday living.
Most of the people with cataracts who came to the camps brought a caretaker along, and the presence of these trusted helpers was one of the biggest ways to motivate people to accept surgery. Faced with the prospect of going to the district hospital, an unfamiliar environment, many were understandably worried or reluctant, but being able to take someone they knew with them helped them to understand that all was going to be well. This was especially the case for women, many of whom asked to have a grandchild accompany them. Often this relative would have been taking care of them back at home as well. If they were also allowed to go to the hospital, the hospital felt less frightening.
During CATCH’s first year, the trachoma programmes we were working with began to change their approach. Some stopped holding outreach camps, swapping to house-to-house searches to identify people, while others had reached elimination thresholds much faster than anticipated so were stopping treatment altogether. This meant CATCH had to change too.
We began to find new ways to tell people what cataracts are and how they can be treated, always mindful of the need to increase access among hard-to-reach groups.
In Mozambique, we used local women-only investment groups in villages to raise awareness about CATCH. We also used radio talk shows that particularly appealed to women and people with disabilities to spread the word. In Malawi, we trained more women as community health workers, who were then better able to persuade other women to get treatment.
We began raising awareness about CATCH through clinics for children under five, because young mothers often bring their mothers-in-law or other older women with them to attend appointments. We also worked with government employees known as health surveillance assistants, who helped us to work with schools and other government-run institutions to communicate messages about CATCH. By working with community and religious leaders, we were also able to pass on information during weddings, funerals and other church services.
We disaggregated patient data by gender from the very beginning of CATCH. Initially in Mozambique, the ratio of men to women receiving cataract operations worked out to be roughly 70%/30%. By the final year, this was more like 60%/40%: a significant increase. But as more women than men are affected by cataracts, these statistics show there is still more to be done.
Although we did a lot to reach women and other marginalised groups and had good strategies on the ground, broader social and cultural issues mean the battle to ensure equitable access to eye health is far from over. Insights such as those generated by CATCH will help us to better understand how these issues play out in the places where we work and adapt our services accordingly, as we strive to ensure everyone in need of eye care is able to access it.
Moses is the former Project Director of CATCH, based in Sightsavers’ Kenya office. He has worked in the development sector for more than 20 years, and specialises in innovative ways to improve health systems in developing countries.
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