Barman and Mishra BMC Geriatrics (2020) 20:71 https://doi.org/10.1186/s12877-020-1438-y

RESEARCH ARTICLE Open Access How does eye care seeking behaviour change with increasing age and visual impairment? Intersectional analysis of older adults in the Indian Debjani Barman* and Manasee Mishra

Abstract Background: Visual impairment disproportionately affects people in the low-income countries. A high proportion of visual impairment can be prevented or cured. Yet, care seeking for eye health is restricted for women and older adults. This article uses the intersectionality approach to understand how eye care seeking behaviour changes in men and women with increase in age and visual impairment in a poor and underserved region of . It brings forth the commonalities and differences between the various groups. Methods: The article is based on qualitative data. Persons aged 50 years and more are categorized into young-old, middle-old and old-old. Men and women with low vision/ high visual impairment have been selected from each of the three age groups. In-depth interviews have been carried out with 24 study participants. Data saturation has been attained. The JHPIEGO Gender Analysis Framework underpins the study. The narrative data has been coded in NVivo 10 software. Results: Various symptoms are associated with visual impairment. The young-old with low vision do not report much difficulty due to visual impairment. Study participants with high visual impairment, and in the older age groups do. Difficulty in the discharge of regular chores due to visual impairment is rarely reported. Impaired vision is considered to be inevitable with advancing age. Care seeking is delayed for eye health. Typically, outpatient care from nearby facilities has been sought by men and women in every group. Inpatient care is limitedly sought, and mostly restricted to men. Eye care seeking behaviour changes among men with increase in age and visual impairment. Women consistently seek less care than men for both outpatient and inpatient eye care. Study participants of both genders become dependent with increasing age and visual impairment. Traditional patriarchal privileges enjoyed by men (such as mobility and economic independence) decrease with age. The vulnerability of women gets compounded with time. Conclusions: The article presents a granulated understanding of eye care seeking behaviour among older adults in India. Such differentials need to be taken cognizance of in programmes promoting universal access to health care. Existing conceptualizations on access to health care need to be revisited. Keywords: Visual impairment, Dependency, Ageing, Older adults, Intersectionality, Qualitative sampling, India, Gender

* Correspondence: [email protected] IIHMR University, Jaipur, India

© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Barman and Mishra BMC Geriatrics (2020) 20:71 Page 2 of 9

Background age are widely regarded as disadvantaging identities in so- Eye health can be largely secured by timely preventive and cial science literature on health. However, personal iden- care seeking measures. It is estimated that, globally, of the tities, material lives and health are governed by a range of 7.3 billion people alive in 2015, more than 440 million intersecting characteristics. The location of the individuals people had compromised eye health status. Of these, 36.0 and groups at the intersection of societal structures and million were blind, 216.6 million had moderate to severe processesshapesone’s experiences. The intersectionality visual impairment and 188.5 million had mild visual im- approach is being increasingly used in health systems re- pairment. The proportion of women was higher in every search to better understand inequality where social cat- category [1]. Approximately 90.0% of the visually impaired egories such as gender, age, class and (dis) ability are in the world live in low-income settings and 82.0% of the considered as ‘mutually constituted and intersecting in dy- people living in blindness are aged 50 years and more [2]. namic and interactive ways’ [10]. This article adopts the Most cases (80.0%) of visual impairment can be prevented lens of intersectionality to examine how the characteristics or cured. Uncorrected refractive errors are the main cause of gender, age and visual impairment intersect in the seek- of moderate and severe visual impairment in the world and ing of eye care in a disadvantaged region of India. The cataract is the leading cause of blindness in low- and mid- methodological approach and the findings in this article dle- income countries (ibid). In a review of 14 studies in are novel, capturing as they do the dynamic and combined Asia, it was found that cataract and uncorrected refractive effects of multiple characteristics on eye care seeking errors were the most common among age related eye behaviour. The article presents a case for looking at the [3]. expected to ‘turn into a rapidly ageing needs of older adults in a nuanced manner. society in the coming decades’ [4]. A recent survey in the country showed that 70.0% of the study population aged Methods 50 years and more have impairments in either near or Aim, design and study setting distance vision [5]. This article is drawn from a larger study carried out to Access to health care in low- and middle- income understand the effects of the intersection of gender with countries incorporates the dimensions of quality, geo- other identities/socio–demographic characteristics on graphic accessibility, availability, financial accessibility eye care seeking behaviour among persons aged 50 years ’ and acceptability of services [6]. Women s access to and more. The study is located in the Sundarbans region health care can be particularly compromised because of of India. The Sundarbans is mostly a deltaic region their gendered existence. Lewallen and Courtright note marking the confluence of the river Ganges with the Bay that the cataract surgical rate is higher for men in devel- of Bengal. Its unique topography is spread across two oping countries. Some reasons for such gender differen- countries (India and Bangladesh). It is a region of cli- tials include the high costs involving transportation to matic uncertainties. As per the 2011 Census of India, the the hospital, loss of wages and expenses incurred during Indian Sundarbans is home to 4,426,259 people [11]. the stay in the hospital. The authors add that poor rural They reside in 54 out of the 106 islands in the Indian women usually have less disposable income or control of Sundarbans [12]. The region is predominantly rural and finances compared to men. Since cataract surgery re- historically an impoverished and underserved area. quires transport to a hospital, women are less likely to Qualitative fieldwork was carried out in two adminis- seek it as it would entail travelling outside their village trative blocks of the Indian Sundarbans. The blocks are for the service [7]. Lower status in the family, restricted located 110 km apart from one another. The names of public mobility and lack of control over economic the blocks have been anonymized for ethical reasons. resources are reasons due to which women have lesser Cases of ageing men and women with visual impairment access to eye care services across the world [8]. were drawn from a quantitative dataset of the larger study. India has pluralistic health systems. Health care is pro- As per the National Programme for Control of Blindness, vided by the government and private players. The country , visual impairment is classified into has an inequitous and fragmented health care market with five categories graded in terms of severity [13]. The five cat- gross rural-urban disparities. Unqualified health care pro- egories are: normal vision, low vision, economic blindness, viders also provide care in the country, especially in areas social blindness and one eye blindness. 1 During the quanti- inadequately served by the formal health care providers. tative data collection phase, a team of optometrists had The coverage of insurance is limited. Typically, high out- of-pocket expenses are borne for seeking health care. For 1National Programme for Control of Blindness, Government of India a country of sub-continental proportions, there are pan- [13] defines the five categories of visual impairment as follows:Normal – Indian gender differentials in access to health care [9]. Vision: > 6/18 in both eyes; Low Vision: < 6/18 6/60 in the better eye; Economic Blindness: < 6/60–3/60 in the better eye; Social Blindness: Health care seeking is contingent upon timely deploy- < 3/60 in the better eye; One Eye Blindness: < 6/60 in one eye and ment of material and non-material resources. Gender and better than 6/18 in the fellow eye; Blind: < 6/60 in the better eye. Barman and Mishra BMC Geriatrics (2020) 20:71 Page 3 of 9

carried out eye testing to identify the level of visual impair- and probes. The guide had been pilot tested. Interviews ment of the ageing study participants and had classified were carried out in the homes of the study participants each person into one of the five categories. Such a list of and in their native language. Prior to the interviews, re- visually impaired persons (n = 442) provided the sampling lationship with the study participants had already been frame for the qualitative ethnographic fieldwork. The established during the optometric tests and the quantita- mean age of the visually impaired persons in the quantita- tive data collection. Study participants knew about our tive dataset was 67 years. A majority of them were illiterate institutional affiliation and contact details. They knew and economically dependent. In order to understand that we were carrying out research and our reasons for intersectionality, the qualitative sample was drawn from doing it. They knew that the lead author was in charge this quantitative dataset. The qualitative research princi- of the study. They had been informed about these ples of purposive selection and extreme case sampling matters. Privacy was largely maintained, with other were adopted for the purpose. Qualitative ethnographic persons being rarely present during the interviews. fieldwork was carried out after the quantitative data col- The average duration of the interviews in this phase lection was over. was 1 h and 20 min. There were no refusals to participate in the study dur- Characteristics of study participants ing the face to face in-depth interview phase. After a gap Three characteristics of the study participants have been of some months, follow up interviews were conducted taken into consideration for inclusion in the sample. telephonically with 12 of the study participants. The These are gender, age and visual impairment. Cases of telephonic interviews were primarily carried out to as- low vision and economic/ social/ one eye blindness were certain that data saturation had been attained for the selected from within each such intersecting group of various domains of information, and that no new aspects gender and age. 2A study participant was either a man emerged. One study participant refused to participate or a woman, belonging to one of the three age groups of during the telephonic interview phase. The reason for young-old (50–64 years), middle-old (65–74 years) or refusal is not known to us. No inconsistencies emerged old-old (75 years or more), and with either low vision or in the narratives of the study participants during the high (economic/ social/ one eye blindness) visual impair- telephonic phase of the fieldwork. Fieldnotes were main- ment. Thus, there were 12 groups of study participants, tained by the researchers throughout the fieldwork and a members of each group belonging to a particular gender, record of the memos was kept. age group and level of visual impairment (Table 1). Twenty four men and women were interviewed. Hindus Analysis and Muslims were represented in almost equal propor- All in-depth interviews were audio recorded. The re- tions in the sample. cordings were transcribed verbatim. The transcripts could not be shared with the study participants. Coding Process of data collection was undertaken in NVivo10 software. We adopted hy- Both authors are females and hold PhD degrees. Both brid coding using a mix of deductive and inductive held faculty positions in a university at the time of the codes [14]. Gender analysis has been defined as ‘a sys- study. They have received professional training on quali- tematic methodology for examining the differences in tative research and have carried out several qualitative roles and norms for women, men, girls and boys; the dif- studies. Qualitative ethnographic fieldwork was itera- ferent levels of power they hold; their differing needs, tively conducted in two phases in the two study sites constraints, and opportunities; and the impact of these during the period December 2015–August 2016. First, differences in their lives’ [15]. The JHPIEGO Gender face to face in-depth interviews were conducted by the Analysis Framework (GAF) [15] provides an analytical lead author with the study participants. An in-depth underpinning for this study. The framework has four do- interview guide had been developed by the authors for mains, viz., access to assets; beliefs and perceptions; the purpose. It contained an indicative list of questions practices and participation; institutions, laws and pol- icies. Power pervades the four domains. It determines 2The criteria of gender and age remained unchanged during the access to and control of assets and decisions ‘over one’s purposive selection of the cases for the qualitative sample. There were body’. Ours being a community-based study, the deduct- very few cases of one eye blindness in the ageing visually impaired population in the study sites. Therefore, cases of social blindness were ive codes in the coding schema were primarily informed taken in villages where those of one eye blindness could not be found by pertinent concepts in GAF in the three domains of (within the given gender and age criteria). Similarly, when cases of access to assets; beliefs and perceptions; and practices social blindness could not be found, then persons with economic and participation. The inductive codes were data driven, blindness were included in the sample. In the article, high visual impairment refers to cases with any one of these three eye conditions primarily descriptive in nature, and as suggested by the (economic/social/one eye blindness). narrative data. Related inductive codes were grouped Barman and Mishra BMC Geriatrics (2020) 20:71 Page 4 of 9

Table 1 Qualitative Sampling Scheme Visual Impairment Young-Old Middle-Old Old-Old (50–64 years) (65–74 years) (75 years or more) Men Women Men Women Men Women Low Vision 2 2 2 2 2 2 High Visual Impairment (economic blindness, social 22 22 2 2 blindness or one eye blindness) Total (24) 4 4 4 4 4 4 together under the corresponding deductive codes to it. There is a sense of normalization of visual impairment form coding categories. The major coding categories among the older adults too. It is considered to be a normal were perceptions about visual impairment; daily life and process of ageing. A local term ‘cholisia’ is used in the dependency; health status and health care seeking. study community to refer to the gradual impairment of Two researchers carried out the coding in a comple- vision with age. A low vision male study participant in the mentary manner. A third person regularly checked the old-old age group remarked how visual impairment emerging coding structure to ascertain its appropriate- (‘eye defect’) is bound to happen with advancing age. ness, and the assignment of appropriate code(s) to any This perception is also shared by men and women given piece of narrative data. The coding tree was thus a old-old study participants with high visual impairment. continually evolving one and agreed upon by the re- The symptoms of visual impairment include hazy vision, searchers. The NVivo10 qualitative dataset for the study cataract (‘chani’), headache, problems in seeing during the is rich in variety and depth, with concepts in GAF ana- day, problems in seeing during the night, watery eyes, and lytically underpinning the study. The dataset has a total problems with near and/or far vision. Various words are of 1958 nodes and the coding structure reaches up to used by the study participants to denote a symptom. The level 12 for the particularly deep mother nodes. The eyes are ‘bound to water’ with advancing age, as was em- constant comparative method [16] has been used to phatically stated by an old-old woman with high visual im- identify patterns within and across the 12 groups of pairment. Study participants themselves are likely to have study participants. Quotations reported in this article are perceived their visual impairment. Gendered idioms of ex- usually English translations of the statements made in pression have been discerned in the narratives pertaining the native language. All quotations have been italicized. to symptoms of visual impairment. Study participants For reasons of confidentiality, only the gender, age group often narrate about their symptoms in the context of their and level of visual impairment of the concerned study gendered activities. For example, difficulties may be re- participant are mentioned alongside the quotation. The ported in the context of sewing for women and outdoor themes have been derived from the data and there is activities for men. consistency between the data presented and the findings. The young-old with low vision do not report much The major themes have been presented as sub-sections difficulty due to visual impairment. Study participants in the section on ‘Results’. Finer details and patterns with high visual impairment, and in the older age groups have been teased out within each theme. The study par- do. Difficulty in the discharge of regular chores (such as ticipants have not provided feedback on the findings. eating, bathing or combing hair) due to visual impair- The various aspects of the qualitative methodology ment is rarely reported by any of the study participants adopted in the study are reported as per COREQ across the various groups. As a study participant said, ‘I guidelines [17]. The filled up COREQ checklist is can do these (regular chores) quite well’ (Male, Old-Old, annexed (Additional file 1). Low Vision). Reduced functioning or hardships encoun- tered are not attributed to impaired vision. Rather, they Results are due to other reasons such as failing health or the Perceptions of visual impairment external environment. Stumbling and falling on the road, References to eye health feature in the narratives of for example, is not perceived to be due to visual impair- every study participant. Study participants in all groups ment. A male study participant explained why tripping associate various symptoms with their visual impair- while walking was not due to the fault in his eyes. ment. However, the narratives are least dense for the Rather, it was a case of walking on an uneven surface group of young-old with low vision. Visual impairment where he accidentally put his foot on a high level (Male, is believed to occur with advancement in age and does Young-Old, Low Vision). not particularly concern the young-old. Persons beyond Participation in economic activities such as sewing, the age of 60 years are said to be particularly affected by weaving nets or farming may get restricted/ discontinued Barman and Mishra BMC Geriatrics (2020) 20:71 Page 5 of 9

with impaired vision. But, visual impairment is unlikely to care belonged to two groups: young-old with high visual be considered to be debilitating. A woman study partici- impairment, and middle-old with low vision. pant in the young-old, low vision group recounted how There is a gendered pattern in seeking care for eye she started using spectacles to continue stitching rugs. health. Mobility and economic independence typically Older study participants may have withdrawn from enjoyed by men (especially those in the young-old and economic activities due to their impaired vision. Women the middle-old groups) enabled them to seek care even study participants narrated how household members it meant travelling to distant places. Women study par- urged them to stop working because of the impairment. ticipants visited nearby facilities. The deductive code of One of them said: ‘Beliefs and Perceptions’ contained narratives explicating prevalent gender norms. Men were more mobile while ‘They (family members) asked me to stop doing work women were usually dependent on others to take them … weaving nets … because I was not able to see. to (far) places. They were also burdened with household They told me not to do it (weaving nets) … Iam chores. As a woman said, ‘Women are probably afraid, unable to do it because of my eyes … what can I do therefore they do not seek services as much (as men). since I cannot see? … I have stopped doing it' They are afraid because they need to do household work (Female, Old-Old, Low Vision) … they do not know what will happen after the treatment (what if they are unable to do household chores? who will Eye care seeking behaviour in persons aged 50 years and do then?) ... Therefore, they are less likely to seek care for more their eyes’ (Female, Middle-Old, Low Vision). Study participants limitedly access health care facilities The restricted (and often dependent) mobility of for their visual impairment. These range from not hav- women and social norms to be protective towards them ing sought any treatment, to a maximum of having vis- are apparent in the narratives of the male study partici- ited three health care facilities. Though delayed, pants. A man narrated how men ‘can travel (on their outpatient care has been sought by most men and own) by bicycle easily. But a woman needs separate women in every group. The delay may be of months, or transportation to be ferried around … such as a motor even years, after the onset of the symptoms – ‘very long’ cycle, a rickshaw or some other vehicle’ (Male, Middle- as many study participants concede. A male study par- Old, High Visual Impairment). Men are also protective ticipant elaborated how he had sought care for blurred towards the women and tend to accompany them on vision after a few years. In his words, ‘I used to paint tar visits. As a man said, ‘Perhaps men can tolerate more … Once tar fell into my eyes and since then I have than women. Or, it may be that we are over protective of blurred vision. I visited the doctor three to four years them. Therefore, we try to rush to their aid’ (Male, later’ (Male, Young-Old, Low Vision). Visual impairment Middle-Old, Low Vision). The combination of women in older adults is considered to be an inevitable, painless being burdened with household chores, their restricted and a non-debilitating condition. As we have seen in the mobility and the social norm to be accompanied by men earlier section, it is not considered to be the reason for results in their limited care seeking for visual restriction of the movement or activities of the older impairment. adults, especially in cases of low vision. Moreover, seek- Inpatient care is limitedly sought, being mostly restricted ing medical care is associated with the old and the in- to men in the young-old and middle-old age groups. Where firm – a population sub-group that the young-old does sought, the study participants are likely to have paid for the not identify with. Distancing herself from such persons, expenses themselves. These include hospitalization and a woman study participant tellingly said that ‘it is the old travel costs. They would have travelled by bus or other ve- who seek care from the doctor’ (Female, Young-Old, High hicles to the health care facility. Sometimes, they would Visual Impairment). Care seeking for eye health assumes have availed of free transport services provided by local low priority in such circumstances. NGOs to take patients to such destinations. Study partici- Outpatient care was typically sought from nearby pants seeking inpatient care may have been accompanied health care providers. Such services were usually offered by others (family members in particular) or would have vis- free of charge by the government or NGOs. These may ited alone (especially in the case of men). have been offered in the neighbourhood or in a neigh- Gender differentials can be discerned in the decision bouring locality within the village. Study participants to seek inpatient care. In the case of the ageing women, would have walked, cycled or availed of local public the decision is taken by other members of the family. transport services to reach the health care facilities offer- Women are also likely to be accompanied by their chil- ing outpatient care. Services of distant health care pro- dren or other relatives. Ageing men themselves took de- viders had been sought by very few study participants cisions on seeking inpatient care and visited health care for outpatient care. The few who sought such distant facilities alone. Access to assets enables the older adults Barman and Mishra BMC Geriatrics (2020) 20:71 Page 6 of 9

to seek inpatient care. However, it is mediated by gen- their economic independence is compromised. It is likely der. Ageing men may take out from their earnings/sav- that the old-old may have reduced earnings or would ings. They may borrow from others to pay for the have altogether withdrawn from economic activities. inpatient services. For the ageing women though, the There is an increase in their (physical and economic) de- money for inpatient care is provided by their husbands pendency on others. Their dominance in the household and/or children. The access to assets and consequently, diminishes. As a male study participant put it, ‘earlier I the seeking of inpatient care for eye health, can be pre- was the guardian of the household … now my sons have carious for the ageing study participants of both genders. grown up and are earning themselves. I seek money from As a male study participant put it succinctly, them’ (Male, Young-Old, Low Vision). The situation is reversed from earlier times when men could support ‘There are families where children own the property others financially and were often the economic backbone forcefully and no longer obey the elderly … then the of the household. Seeking care for their eyes is affected problem is who will take care of the elderly, who will in such a situation of reduced privileges with compro- take him/her, pay the money, this is the problem, mised mobility, economic independence and position in there are many such families. … if I have property, the household. One study participant said, ‘I can easily and wish to visit a certain facility, they are bound to ask money from my sons, but you know, it is not good to take me there. If you do not have property, even if pressurize them for my own benefit. It will look like lux- you beg, they will not take you there’ (Male, Young- ury’ (Male, Middle-Old, Low Vision). Another man Old, Low Vision) recounted how he did not seek medical care for his eyes because of economic reasons. In his words, ‘I could not Decreasing privileges of ageing men arrange for the money and hence did not go (for getting Eye care seeking behaviour changes for men with in- my eyes treated), my sons will not give the money’ (Male, crease in age and visual impairment. The group of Old-Old, High Visual Impairment). middle-old with high visual impairment and the two old-old groups seek less care. This is true for both out- Compounding vulnerability of ageing women patient and inpatient care for eye health. Compared to their male counterparts, female study par- Excepting old-old men with high visual impairment, ticipants consistently seek less outpatient and inpatient male study participants are usually engaged in product- care for eye health. There is no perceptible difference ive activities (such as manual farming). The need for hu- in the seeking of eye care by women across age groups man support has been reported by all male study and levels of visual impairment. They are likely to visit participants. Such human support may be sought for the nearby health care facilities for outpatient care for food, washing of clothes, or purchasing things from the their eyes. Seeking inpatient care for their eyes is market. Human support is most sought by men in the limited. old-old groups of low vision and high visual impairment. Though sporadically, female study participants of all Both groups in that category report needing support for the three age groups report engagement with household buying or visiting the doctor. Men in all work. Women in all groups (except the old-old with groups report the use of aids in their daily lives. The use high visual impairment) may be engaged in productive of walking sticks has been reported by men in the activities such as winnowing grains and cutting fish. middle-old and old-old age groups. Taking a lantern or Similar to the male study participants, the need for hu- torch while going to the toilet at night has been re- man support has been reported by all women study par- ported. Ageing men may find it difficult to carry out ticipants. A woman’s daughter-in-law or grand children routine chores such as answering the calls of nature, may help her in wearing clothes. They may clean her reading or praying. They may increasingly seek the com- clothes. A person may get water from the tube wells or pany of other people for going out. They may restrict the ponds so that she may take her bath. Cooking is gen- outdoor activities in order to be in familiar surround- erally done by the daughter-in-law. A woman said, ‘Ino ings. The narratives are telling. longer cook. I used to do it so well earlier’ (Female, Middle-Old, High Visual Impairment). Another woman ‘I (no longer) go outside for offering Namaz (Islamic recounted how she has stopped cooking for the house- prayer) after dusk. What if I fall down somewhere? I hold and is increasingly dependent on others for routine need to bring the book close enough so that I can chores such as bathing and cleaning clothes. She said, read’ (Male, Old-Old, High Visual Impairment) ‘It’s been 10-12 years since I stopped cooking (for the household). Who will do my chores for me? Whoever gets The patriarchal privileges traditionally enjoyed by men some time helps me out’ (Female, Old-Old, Low Vision). decrease with age. Their mobility gets restricted and With increase in age, things may come to such a pass Barman and Mishra BMC Geriatrics (2020) 20:71 Page 7 of 9

that food is served to the woman, she being typically identify themselves with the ageing, infirm population. dependent on her daughter(s)-in-law for it. This may explain why care seeking for eye health is low The economic dependence of the female study par- for the group. For the other groups of study participants, ticipants continues into old age. Never self-reliant, a combination of factors results in the manifest eye care they need to take money from their husbands and/or seeking behaviour. Unlike physical infirmity, visual im- sons for meeting expenses. Two female study partici- pairment is not considered to be debilitating. There may pants (both in the young-old age group) narrated how be gradual withdrawal from economic activities. Carry- they were economically dependent on their sons. In ing out routine activities may get increasingly challen- their words: ging. However, study participants are likely to attribute their dependency to decreased physical capacity rather ‘Whenever there is a need to buy something or to than impaired vision. Visual impairment is perceived to spend something somewhere, my younger son bears be inevitable in old age. It is a painless condition too. the expenses’ (Female, Young-Old, Low Vision) With increasingly restricted activities within and outside the house, seeking of care for impaired vision assumes ‘My elder son is erratic in matters of money. Some- low priority. There is delayed care seeking for visual times he gives, at other times he does not. He may impairment. suddenly give some money after six to nine months’ There are distinct gendered patterns in the economic (Female, Young-Old, High Visual Impairment) independence and mobility of the study participants. Men are most mobile in the young-old and middle-old Support needed for buying medicines or visiting the doc- age groups. Their mobility decreases as they grow older. tor is not as pronounced in the narratives of the female With increasing age and visual impairment, their de- study participants. This may possibly be due to the fact pendency on human and non-human support increases. that women typically seek outpatient care from nearby Their economic independence is often compromised facilities. They are usually accompanied by other (male) and their position in the household diminishes. This re- members of the family who bear such expenses. Women sults in lessened care seeking for eye health by men for across the different groups report the use of aids such as both outpatient and inpatient care. The patriarchal privi- walking sticks and torches. As in the case of the male leges that they traditionally enjoy are offset by advancing study participants, the use of walking sticks is especially age and visual impairment. Coston and Kimmel observe reported from the age group of middle-old onwards. that male privileges can be ‘compromised’ by disability Physical dependency increases with age induced debility. status, sexuality and class. They term such situations as The traditional gendered roles of doing housework (e.g. ‘marginalized masculinities’ [18]. Women, on the other cooking and cleaning) and child care get reduced with hand, are generally restricted in their care seeking for increasing age. Their economic dependence continues visual impairment. They typically seek nearby outpatient into old age. The vulnerability of women gets com- care. Neither economically self-sufficient nor independ- pounded with age. ently mobile, they gradually withdraw from traditional gender roles such as cooking, cleaning and childcare. Advancing age and visual impairment compound their Discussion vulnerability. With increasing dependency on human The foregoing section presents a granulated picture of and non-human support, seeking eye care remains lim- health care seeking for visual impairment by ageing men ited for them as they age. and women in the Indian Sundarbans. Gendered Increasing dependency with the advancement of age in privileges and vulnerabilities play out differently with both men and women explains why narratives on eye advancing age and levels of visual impairment. To our care seeking are densest for two groups - the young-old knowledge, such an explication of the intersection of with high visual impairment, and the middle-old with gender, age and visual impairment on eye care seeking low vision. In both genders, these two groups have per- behaviour is new to scientific literature. This article also ceived severity of their visual impairment and are gener- presents a methodological innovation in the empirical ally able to seek care. The gendered nature of power exploration of intersectionality. The sampling design plays out therein. The differential nature of ‘who has, customizes existing principles of qualitative research can acquire, and can expend assets and decisions over sampling (purposive sampling, extreme case sampling) one’s body’ [15] shapes the experiences of men and to present a sample that captures the intersecting women in seeking care for their visual impairment. This characteristics of gender, age and visual impairment. article thus contributes to a layered understanding of ac- The young-old with low vision have perceived low cess to eye care. Dimensions such as geographic and fi- severity of their visual impairment. They also do not nancial accessibility are known to be gendered, with Barman and Mishra BMC Geriatrics (2020) 20:71 Page 8 of 9

women being particularly disadvantaged. However, as particular context of a lower middle income country our results show, access to eye care can be challenging such as India. for both men and women with age related infirmity, in- The recently released World Report on Vision [24] creasing dependency and change in socio-economic sta- proposes Integrated People-Centred Eye Care (IPEC) as tus with advancing age. Our study provides evidence to an approach to strengthen health systems to provide eye revisit existing conceptualizations on access to health care through the life course. The four strategies of IPEC care [e.g. 6, 19] and add/refine elements that are reflect- are: (i) engaging and empowering people and communi- ive of the complex contexts of the people in need of ties (ii) reorienting the model of care based on a strong care. In a recent conceptualization of patient-centred (iii) coordinating services within and across access to health care, Levesque and colleagues define sectors, and (iv) creating an enabling environment, spe- ‘access as the opportunity to identify healthcare needs, cifically the inclusion of eye care in national health stra- to seek healthcare services, to reach, to obtain or use tegic plans, the integration of relevant eye care data health care services and to actually have the need for within the health information systems, and the planning services fulfilled’. They ‘conceptualise five dimensions of of the eye care workforce according to population needs. accessibility’. These are: approachability; acceptability; The renewed commitment to primary care in IPEC is availability and accommodation; affordability and appro- welcome as it holds the promise to provide eye care that priateness. The authors say that the five dimensions of is available, accessible and sensitive to local needs. It accessibility ‘interact’ with five corresponding abilities of would mean responding to the needs of older adults in populations ‘to generate access’. The five corresponding their complex contexts. abilities are: ability to perceive, ability to seek, ability to Intersectional experiences are shaped by numerous reach, ability to pay and ability to engage [19]. Our study characteristics and identities. The present article is re- shows that while differences exist between the groups, stricted to three characteristics (gender, age and visual the five corresponding abilities change and usually get impairment) in order to exemplify how intersectionality compromised with advancing age in the context of eye shapes eye care seeking behaviour in a disadvantaged care. The intersectional manner in which study par- region of India. Though we have studied some more ticipants experience their lives adds further complexity characteristics, data suggested that these three have to the conceptualization formulated by Levesque and been crucial in the seeking of eye care. The restriction to colleagues. It calls for greater recognition of the situated- three characteristics marks a limitation since, theoretic- ness of the population groups in need of care. ally, more characteristics and identities could have been Some findings of the present article corroborate with taken into consideration in the empirical exploration of existing scientific literature. Lack of perceived need/low intersectionality. This limitation can be overcome by need has been seen to be a major reason why people subsequent empirical research where a wider range of with visual impairment do not access eye care services characteristics and identities is expected to provide an in India [20] and neighbouring Pakistan [21]. Multiple even more granulated picture of intersectional experi- barriers have been cited in accessing eye care services in ences and care seeking behaviour. India [22]. Though women are more likely to be affected There is another limitation of this study. Narratives of by cataract, men tend to receive more services pertaining the study participants constitute the empirical basis of to it (ibid). Worldwide too, women have restricted this article. While they are rich and revealing of the access to eye care services. These are due to multiple intersectional experiences, we do not know if care seek- factors, ranging from ‘sociocultural influences and ing for eye health has been appropriate. The study par- financial limitations to education level of the patient and ticipants have poor literacy status and are based in the awareness of the care provider’. Transportation is a Indian Sundarbans. Their perceptions of need and what common barrier for women [23]. constitutes care also determine the resultant care seek- However, the manifestation of the intersecting charac- ing behaviour. The narrative accounts are telling but teristics of gender, age and visual impairment in eye care need to be complemented by systems records of the seeking is little understood. The concept of intersection- quality of care received and the adequacy thereof. This is ality receives a synergistic boost as equity in health gains beyond the scope of our study, restricted as it is to the traction in academics, policy making and programme understanding of eye care seeking behaviour of older implementation. Larson and colleagues observe that ap- adults in the Indian Sundarbans. plications of intersectionality in public health has ‘mostly increased’ after 2009 [10]. They identify 86 articles, only Conclusions 14 of which are on low- and middle- income countries. The health of older adults gains attention as populations Thus, this article makes methodological and empirical age in countries across the world. The socio-demographic contributions to intersectionality in public health, in the diversities of the older adult population necessitate a Barman and Mishra BMC Geriatrics (2020) 20:71 Page 9 of 9

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