Prevalence and causes of blindness and visual impairment in Kogi state, Nigeria-Findings from a Rapid assessment of avoidable blindness survey.

PURPOSE: To determine the prevalence and causes of blindness and visual impairment among adults in Kogi, Nigeria. METHODS: A Rapid assessment of avoidable blindness (RAAB) protocol was used with additional tools measuring disability and household wealth to measure the prevalence of blindness and visual impairment (VI) and associations with sex, disability, wealth, cataract surgical coverage and its effectiveness. RESULTS: Age- and sex-adjusted all-cause prevalence of bilateral blindness was 3.6% (95%CI 3.0-4.2%), prevalence of blindness among people living with additional, non-visual disabilities was 38.3% (95% CI 29.0-48.6%) compared to 1.6% (95%CI 1.2-2.1%; [Formula: see text] = 771.9, p<0.001) among people without additional disabilities. Cataract was the principal cause of bilateral blindness (55.3%). Cataract surgical coverage (CSC) at visual acuity (VA) 3/60 was 48.0%, higher among men than women (53.7% vs 40.3%); 12.0% among people with non-visual disabilities; 66.9% among people without non-visual disabilities, being higher among people in the wealthiest two quintiles (41.1%) compared to the lowest three (24.3%). Effective Cataract Surgical Coverage at Visual Acuity 6/60 was 31.0%, higher among males (34.9%) than females (25.5%), low among people with additional, non-visual disabilities (1.9%) compared to people with no additional disabilities (46.2%). Effective CDC was higher among people in the wealthiest two quintiles (411%) compared to the poorest three (24.3%). Good surgical outcome (VA>6/18) was seen in 61 eyes (52.6%) increasing to 71 (61.2%) eyes with best correction. Cost was identified as the main barrier to surgery. CONCLUSION: Findings suggest there exists inequalities in eye care with women, poorer people and people with disabilities having a lower Cataract Surgical Coverage, thereby, underscoring the importance of eye care programs to address these inequalities.

Livelihood outcomes in a cohort of youth with disabilities following participation in an economic empowerment programme in rural Uganda.

BACKGROUND: Little evidence exists on the livelihoods of young people with disabilities in low- and middle-income settings. OBJECTIVE: This study examined employability and livelihood outcomes among a cohort of youth with disabilities who participated in an economic empowerment programme in rural Uganda. METHODS: Prospective cohort of youth with disabilities participating in an economic empowerment programme in rural Uganda. Livelihood outcomes of participants were assessed through structured interviews at baseline (n = 297) and again at 12 months (n = 252) and analysed using chi-squared tests and generalized estimating equations. RESULTS: Of 297 participants at baseline, 144 (48%) were women and the mean age was 21.7 years. At 12 months follow-up, participants were significantly more likely to have a job (OR 3.04, 95% CI 2.10-4.39); to have accessed finance (OR 5.52, 95% CI 3.18-9.56); and experienced community support (OR 2.23, 95% CI 1.51-3.29) compared with baseline. There were no statistically significant changes in having enough money for food or in having experienced community discrimination. CONCLUSIONS: The findings suggest that targeted vocational skills training, apprenticeships scheme and a start-up financial package may improve the livelihoods of young people living with disabilities in rural African settings.

Understanding the role of lady health workers in improving access to eye health services in rural Pakistan - findings from a qualitative study.

BACKGROUND: In 1994, the Lady Health Workers (LHWs) Programme was established in Pakistan to increase access to essential primary care services and support health systems at the household and community levels. In Khyber Pakhtunkhwa (KPK) province in northern Pakistan, eye care is among the many unmet needs that LHWs were trained to address, including screening and referral of people with eye conditions to health facilities. However, despite an increase in referrals by LHWs, compliance with referrals in KPK has been very low. We explored the role of LHWs in patient referral and the barriers to patient compliance with referrals. METHODS: Qualitative methodology was adopted. Between April and June 2019, we conducted eight focus group discussions and nine in-depth interviews with 73 participants including patients, LHWs and their supervisors, district managers and other stakeholders. Data were analysed thematically using NVivo software version 12. RESULTS: LHWs have a broad understanding of basic health care and are responsible for a wide range of activities at the community level. LHWs felt that the training in primary eye care had equipped them with the skills to identify and refer eye patients. However, they reported that access to care was hampered when referred patients reached hospitals, where disorganised services and poor quality of care discouraged uptake of referrals. LHWs felt that this had a negative impact on their credibility and on the trust and respect they received from the community, which, coupled with low eye health awareness, influenced patients' decisions about whether to comply with a referral. There was a lack of trust in the health care services provided by public sector hospitals. Poverty, deep-rooted gender inequities and transportation were the other reported main drivers of non-adherence to referrals. CONCLUSIONS: Results from this study have shown that the training of LHWs in eye care was well received. However, training alone is not enough and does not result in improved access for patients to specialist services if other parts of the health system are not strengthened. Pathways for referrals should be agreed and explicitly communicated to both the health care providers and the patients.

Factors associated with the uptake of cataract surgery and interventions to improve uptake in low- and middle-income countries: A systematic review.

Despite significant evidence around barriers hindering timely access to cataract surgery in low- and middle-income countries (LMICs), little is known about the strategies necessary to overcome them and the factors associated with improved access. Despite significant evidence that certain groups, women for example, experience disproportionate difficulties in access, little is known about how to improve the situation for them. Two reviews were conducted recently: Ramke et al., 2018 reported experimental and quasi-experimental evaluations of interventions to improve access of cataract surgical services, and Mercer et al., 2019 investigated interventions to improve gender equity. The aim of this systematic review was to collate, appraise and synthesise evidence from studies on factors associated with uptake of cataract surgery and strategies to improve the uptake in LMICs. We performed a literature search of five electronic databases, google scholar and a detailed reference review. The review identified several strategies that have been suggested to improve uptake of cataract surgery including surgical awareness campaigns; use of successfully operated persons as champions; removal of patient direct and indirect costs; regular community outreach; and ensuring high quality surgeries. Our findings provide the basis for the development of a targeted combination of interventions to improve access and ensure interventions which address barriers are included in planning cataract surgical services. Future research should seek to examine the effectiveness of these strategies and identify other relevant factors associated with intervention effects.

Prevalence of Visual Impairment and Coverage of Cataract Surgical Services: Associations with Sex, Disability, and Economic Status in Five Diverse Sites.

PURPOSE: Prevalence of visual impairment (VI) and access to services can vary significantly across and between different population groups. With renewed focus on universal health coverage and leaving no one behind, it is important to understand factors driving inequitable eye health. This paper presents results from five population-based surveys where prevalence of VI and cataract surgical coverage (CSC) were measured and examined for differences by sex, economic-status, and disability. METHODS: Rapid assessments of avoidable blindness took place in four rural sites: Kalahandi, Jhabua and Sitapur in India; and Singida, Tanzania; and one urban site: Lahore, Pakistan. In addition, the Equity Tool was used to measure economic status and the Washington Group Short Set was used to measure disability. Prevalence of VI and CSC were calculated and associations with sex, disability, and relative wealth examined. RESULTS: Prevalence of VI varied from 1.9% in Lahore to 15.0% in Kalahandi. CSC varied from 39.1% in Singida to 84.0% in Lahore. Additional disability was associated with greater levels of VI in all sites and lower CSC in Singida. Being female was associated with higher VI in Kalahandi, Lahore and Singida and lower CSC in Lahore and Singida. Being poorer was associated with higher VI in Singida and lower CSC in Singida and Sitapur. CONCLUSION: Relationships between VI and relative wealth, sex, and disability are complex and variable. Although certain characteristics may be associated with lower coverage or worse outcomes, they cannot be generalized and local data are vital to tailor services to achieve good coverage.

Integrating Geospatial Data and Measures of Disability and Wealth to Assess Inequalities in an Eye Health Survey: An Example from the Indian Sunderbans.

The Sunderbans are a group of delta islands that straddle the border between India and Bangladesh. For people living on the Indian side, health services are scarce and the terrain makes access to what is available difficult. In 2018, the international non-governmental organisation Sightsavers and their partners conducted a population-based survey of visual impairment and coverage of cataract and spectacle services, supplemented with tools to measure equity in eye health by wealth, disability, and geographical location. Two-stage cluster sampling was undertaken to randomly select 3868 individuals aged 40+ years, of whom 3410 were examined. Results were calculated using standard statistical processes and geospatial approaches were used to visualise the data. The age-sex adjusted prevalence of blindness was 0.8%, with higher prevalence among women (1.1%). Cataract Surgical Coverage for eyes at visual acuity (VA) 3/60 was 86.3%. The study did not find any association between visual impairment and wealth, however there were significant differences by additional (non-visual) disabilities at all levels of visual impairment. Geospatial mapping highlighted blocks where higher prevalence of visual impairment was identified. Integrating additional tools in population-based surveys is critical for measuring eye health inequalities and identifying population groups and locations that are at risk of being left behind.

Education and social inclusion of people with disabilities in five countries in West Africa: a literature review.

PURPOSE: An estimated 1 billion people worldwide live with some form of disability. With the adoption of the Sustainable Development Goals and the "Leave no one behind" agenda, there is a global momentum to ensure that disadvantaged groups, not least people with disabilities, are included and accounted for, in mainstream development efforts. However, in many low-income settings little is known about disability and the policies and programs in place to improve the lives of those affected. METHOD: This literature review describes the extent and quality of published and unpublished literature on education and social inclusion of people with disabilities in five West African countries: Cameroon, Liberia, Mali, Sierra Leone and Senegal. RESULTS: Fifty-four unique documents met inclusion criteria of the review and described related policy and legislation; national and international stakeholders; intervention programs and primary research related to disability and inclusion. The majority of documents were from Sierra Leone (19); and four described more than one country. Primary research included mainly qualitative studies and cross-sectional surveys; 33 sources were critically appraised with the majority being attributed unclear risk of bias (20). CONCLUSIONS: The findings call for (i) standardized tools for monitoring the implementation of programs and policies at national level; (ii) improved stakeholder coordination mechanisms; (iii) development and adoption of coordinated approaches to measuring disability and social exclusion; (iv) rigorous evaluations of the effectiveness of disability programs and (v) disaggregation of routine data by disability. Implication for Rehabilitation There is a need for standardized tools for monitoring the implementation of programs and policies at national level. Countries that have not yet ratified the UNCRPD or the protocol should be supported to do so. Stakeholder coordination mechanisms need to be improved. Improved coordination between stakeholders involved in disability at the country level could help improve the quality of services delivered. Development and adoption of coordinated approaches is key to measuring disability and social exclusion. There are few, if any, rigorous evaluation of the effectiveness of disability-specific evaluations in the five countries. There is a need for disaggregation of routine data from development programs by disability to inform implementation.

Ensuring Universal Access to Eye Health in Urban Slums in the Global South: The Case of Bhopal (India).

Sightsavers is an international organisation working with partners in over 30 countries to eliminate avoidable blindness and help people with disabilities participate more fully in society. In the context of its Urban Eye Health Programme in Bhopal (India), the organisation launched a pilot approach aimed at developing an Inclusive Eye Health (IEH) model and IEH Minimum Standards. Accessibility audits were conducted in a tertiary eye hospital and four primary vision centres located within urban slums, addressing the accessibility of physical infrastructures, communication and service provision. The collection and analysis of disaggregated data inform the inclusion strategy and provide a baseline to measure the impact of service provision. Trainings of eye health staff and sensitisation of decision makers on accessibility, Universal Design, disability and gender inclusion are organised on a regular basis. A referral network is being built to ensure participation of women, people with disabilities and other marginalised groups, explore barriers at demand level, and guarantee wider access to eye care in the community. Finally, advocacy interventions will be developed to raise awareness in the community and mainstream disability and gender inclusion within the public health sector. Founded on principles of Universal Design, accessibility and participation, and in line with international human rights treaties, Agenda 2030 and the Sustainable Development Goals (SDGs), Sightsavers' IEH model ultimately aims to develop a sustainable, scalable and universally accessible system-strengthening approach, capable of ensuring more inclusive services to people with disabilities, women and other marginalised groups, and designed to more effectively meet the health needs of the entire population.

Factors affecting cataract surgical coverage and outcomes: a retrospective cross-sectional study of eye health systems in sub-Saharan Africa.

BACKGROUND: Recently there has been a great deal of new population based evidence on visual impairment generated in sub-Saharan Africa (SSA), thanks to the Rapid Assessment of Avoidable Blindness (RAAB) survey methodology. The survey provides information on the magnitude and causes of visual impairment for planning services and measuring their impact on eye health in administrative "districts" of 0.5-5 million people. The survey results describing the quantity and quality of cataract surgeries vary widely between study sites, often with no obvious explanation. The purpose of this study was to examine health system characteristics that may be associated with cataract surgical coverage and outcomes in SSA in order to better understand the determinants of reducing the burden of avoidable blindness due to cataract. METHODS: This was a descriptive study using secondary and primary data. The outcome variables were collected from existing surveys. Data on potential district level predictor variables were collected through a semi-structured tool using routine data and key informants where appropriate. Once collected the data were coded and analysed using statistical methods including t-tests, ANOVA and the Kruskal-Wallis analysis of variance test. RESULTS: Higher cataract surgical coverage was positively associated with having at least one fixed surgical facility in the area; availability of a dedicated operating theatre; the number of surgeons per million population; and having an eye department manager in the facility. Variables that were associated with better outcomes included having biometry and having an eye department manager in the facility. CONCLUSIONS: There are a number of health system factors at the district level that seem to be associated with both cataract surgical coverage and post-operative visual acuity outcomes. This study highlights the needs for better indicators and tools by which to measure and monitor the performance of eye health systems at the district level. It is unlikely that epidemiological data alone is sufficient for planning eye health services within a district and health managers and study coordinators need to consider collecting supplementary information in order to ensure appropriate planning can take place.

Factors mediating HIV risk among female sex workers in Europe: a systematic review and ecological analysis.

OBJECTIVES: We reviewed the epidemiology of HIV and selected sexually transmitted infections (STIs) among female sex workers (FSWs) in WHO-defined Europe. There were three objectives: (1) to assess the prevalence of HIV and STIs (chlamydia, syphilis and gonorrhoea); (2) to describe structural and individual-level risk factors associated with prevalence and (3) to examine the relationship between structural-level factors and national estimates of HIV prevalence among FSWs. DESIGN: A systematic search of published and unpublished literature measuring HIV/STIs and risk factors among FSWs, identified through electronic databases published since 2005. 'Best' estimates of HIV prevalence were calculated from the systematic review to provide national level estimates of HIV. Associations between HIV prevalence and selected structural-level indicators were assessed using linear regression models. STUDIES REVIEWED: Of the 1993 papers identified in the search, 73 peer-reviewed and grey literature documents were identified as meeting our criteria of which 63 papers provided unique estimates of HIV and STI prevalence and nine reported multivariate risk factors for HIV/STI among FSWs. RESULTS: HIV in Europe remains low among FSWs who do not inject drugs (<1%), but STIs are high, particularly syphilis in the East and gonorrhoea. FSWs experience high levels of violence and structural risk factors associated with HIV, including lack of access to services and working on the street. Linear regression models showed HIV among FSWs to link with injecting drug use and imprisonment. CONCLUSIONS: Findings show that HIV prevention interventions should be nested inside strategies that address the social welfare of sex workers, highlighting in turn the need to target the social determinants of health and inequality, including regarding access to services, experience of violence and migration. Future epidemiological and intervention studies of HIV among vulnerable populations need to better systematically delineate how microenvironmental and macroenvironmental factors combine to increase or reduce HIV/STI risk.