Blood pressure and the hypertension care cascade in The Gambia: Findings from a nationwide survey.

Community treatment of hypertension in sub-Saharan Africa is hampered by gaps at several stages of the care cascade. We compared blood pressure (BP) levels (systolic, diastolic and pulse pressures) in four groups of participants by hypertension and treatment status. We conducted a nationally representative survey of adults 35 years and older using a multistage sampling strategy based on the 2013 Gambia Population and Housing Census. The BP measurements were taken in triplicate 5 min apart, and the average of the last two measurements was used for analysis. Systolic and diastolic BP levels and pulse pressure were compared by hypertension status using mean and 95% confidence intervals (CI). 53.1% of the sample were normotensive with mean systolic BP (SBP) of 119.2 mmHg (95% CI, 118.7-119.6) and diastolic BP (DBP) of 78.1 mmHg (77.8-78.3). Among individuals with hypertension, mean SBP was 148.7 mmHg (147.7-149.7) among those unaware of their hypertension, 152.2 mmHg (151.0-153.5) among treated individuals and was highest in untreated individuals at 159.3 mmHg (157.3-161.2). The findings were similar for DBP levels, being 93.9 mmHg (93.4-94.4) among the unaware, 95.1 mmHg (94.4-95.8) among the treated and highest at 99.1 mmHg (98.1-100.2) in untreated participants. SBP and DBP were higher in men, and SBP was as expected higher in those aged ≥55 years. BP level was similar in urban and rural areas. Our data shows high BP levels among participants with hypertension including those receiving treatment. Efforts to reduce the health burden of hypertension will require inputs at all levels of the care cascade.

Prevalence of hypertension, diabetes, obesity, multimorbidity, and related risk factors among adult Gambians: a cross-sectional nationwide study.

BACKGROUND: As countries progress through economic and demographic transition, chronic non-communicable diseases (NCDs) overtake a previous burden of infectious diseases. We investigated the prevalence of hypertension, diabetes, obesity, and multimorbidity in older adults in The Gambia. METHODS: We embedded a survey on NCDs into the nationally representative 2019 Gambia National Eye Health Survey of adults aged 35 years or older. We measured anthropometrics, capillary blood glucose, and blood pressure together with sociodemographic information, personal and family health history, and information on smoking and alcohol consumption. Hypertension was defined as systolic blood pressure of 140 mmHg or more, diastolic blood pressure of 90 mmHg or more, or receiving treatment for hypertension. Diabetes was defined as fasting capillary blood glucose of 7 mmol/L or more, random blood glucose of 11·1mmol/L or more, or previous diagnosis or treatment for diabetes. Overweight was defined as BMI of 25-29·9 kg/m2 and obesity as 30 kg/m2 or more. Multimorbidity was defined as the coexistence of two or more conditions. We calculated weighted crude and adjusted estimates for each outcome by sex, residence, and selected sociodemographic factors. FINDINGS: We analysed data from 9188 participants (5039 [54·8%] from urban areas, 6478 [70·5%] women). The prevalence of hypertension was 47·0%; 2259 (49·3%) women, 2052 (44·7%) men. The prevalence increased with age, increasing from 30% in those aged 35-45 years to over 75% in those aged 75 years and older. Overweight and obesity increased the odds of hypertension, and underweight reduced the odds. The prevalence of diabetes was 6·3% (322 [7·0%] women, 255 [5·6%] men), increasing from 3·8% in those aged 35-44 years to 9·1% in those aged 65-75 years, and then declining. Diabetes was much more common among urban residents, especially in women (peaking at 13% by age 65 years). Diabetes was strongly associated with BMI and wealth index. The prevalence of obesity was 12·0% and was notably higher in women than men (880 [20·2%] vs 170 [3·9%]). Multimorbidity was present in 932 (10·7%), and was more common in women than men (694 [15·9] vs 238 [5·5]). The prevalence of smoking was 9·7%; 5 (0·1%) women, 889 (19·3%) men. Alcohol consumption in the past year was negligible. INTERPRETATION: We have documented high levels of NCDs and associated risk factors in Gambian adults. This presents a major stress on the country's fragile health system that requires an urgent, concerted, and targeted mutisectoral strategy. FUNDING: The Queen Elizabeth Diamond Jubilee Trust and Wellcome Trust.

Evaluating the hypertension care cascade in middle-aged and older adults in The Gambia: findings from a nationwide survey.

Background: Hypertension is a major public health problem in sub-Saharan Africa with poor treatment coverage and high case-fatality rates. This requires assessment of healthcare performance to identify areas where intervention is most needed. To identify areas where health resources should be most efficiently targeted, we assessed the hypertension care cascade i.e., loss and retention across the various stages of care, in Gambian adults aged 35 years and above. Methods: This study was embedded within the nationally representative 2019 Gambia National Eye Health Survey of adults ≥35 years. We constructed a hypertension care cascade with four categories: prevalence of hypertension (defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg, and/or current use of medication prescribed for hypertension); those aware of their diagnosis; those treated; and those with a controlled blood pressure (defined as blood pressure <140/90 mmHg). Analyses were age- and sex-standardised to the population structure of The Gambia. Logistic regression was used to assess the socio-demographic factors associated with prevalence, awareness, treatment and control of hypertension. Findings: Of 9171 participants with data for blood pressure, the prevalence of hypertension was 47.0%. Among people with hypertension, the prevalence of awareness was 54.7%, the prevalence of hypertension treatment was 32.5%, and prevalence of control was 10.0% with little difference between urban and rural residence. The cascade of care performance was better in women. However, there was no difference in achieving blood pressure control between men and women who were receiving treatment. Female sex, older age and higher body mass index were associated with higher hypertension awareness whilst having an occupation compared to being unemployed was associated with higher odds of being treated. Patients in the underweight category had higher odds of achieving blood pressure control. Interpretation: There is a high prevalence of hypertension and low performance of the health care system that impact on the hypertension care cascade among middle-aged and older adults in The Gambia. Addressing the full cascade will be paramount especially in reducing the mounting prevalence and improving diagnosis of patients with hypertension, where the greatest dividends will be gained. Funding: The Queen Elizabeth Diamond Jubilee Trust, Wellcome Trust.

Prevalence and impact of combined vision and hearing (dual sensory) impairment: A scoping review.

Hearing and vision impairments are common globally. They are often considered separately in research, and in planning and delivering services. However, they can occur concurrently, termed dual sensory impairment (DSI). The prevalence and impact of hearing and vision impairment have been well-examined, but there has been much less consideration of DSI. The aim of this scoping review was to determine the nature and extent of the evidence on prevalence and impact of DSI. Three databases were searched: MEDLINE, Embase and Global Health (April 2022). We included primary studies and systematic reviews reporting the prevalence or impact of DSI. No limits were placed on age, publication dates, or country. Only studies where the full text was available in English were included. Two reviewers independently screened titles, abstract, full texts. Data were charted by two reviewers independently using a pre-piloted form. The review identified 183 reports of 153 unique primary studies and 14 review articles. Most evidence came from high-income countries (86% of reports). Prevalence varied across reports, as did age groups of participants and definitions used. The prevalence of DSI increased with age. Impact was examined across three broad groups of outcomes-psychosocial, participation, and physical health. There was a strong trend towards poorer outcomes for people with DSI across all categories compared to people with one or neither impairment, including activities of daily living (worse for people with DSI in 78% of reports) and depression (68%). This scoping review highlights that DSI is a relatively common condition with substantial impact, particularly among older adults. There is a gap in evidence from low and middle-income countries. There is a pressing need for a consensus position on the definition(s) of DSI and standardisation of reporting age groups to enable reliable estimates to be ascertained and compared and responsive services developed.

Socioeconomic position and eye health outcomes: identifying inequality in rapid population-based surveys.

OBJECTIVE: Monitoring health outcomes disaggregated by socioeconomic position (SEP) is crucial to ensure no one is left behind in efforts to achieve universal health coverage. In eye health planning, rapid population surveys are most commonly implemented; these need an SEP measure that is feasible to collect within the constraints of a streamlined examination protocol. We aimed to assess whether each of four SEP measures identified inequality-an underserved group or socioeconomic gradient-in key eye health outcomes. DESIGN: Population-based cross-sectional survey. PARTICIPANTS: A subset of 4020 adults 50 years and older from a nationally representative sample of 9188 adults aged 35 years and older in The Gambia. OUTCOME MEASURES: Blindness (presenting visual acuity (PVA) <3/60), any vision impairment (VI) (PVA <6/12), cataract surgical coverage (CSC) and effective cataract surgical coverage (eCSC) at two operable cataract thresholds (<6/12 and <6/60) analysed by one objective asset-based measure (EquityTool) and three subjective measures of relative SEP (a self-reported economic ladder question and self-reported household food adequacy and income sufficiency). RESULTS: Subjective household food adequacy and income sufficiency demonstrated a socioeconomic gradient (queuing pattern) in point estimates of any VI and CSC and eCSC at both operable cataract thresholds. Any VI, CSC <6/60 and eCSC <6/60 were worse among people who reported inadequate household food compared with those with just adequate food. Any VI and CSC <6/60 were worse among people who reported not enough household income compared with those with just enough income. Neither the subjective economic ladder question nor the objective asset-wealth measure demonstrated any socioeconomic gradient or pattern of inequality in any of the eye health outcomes. CONCLUSION: We recommend pilot-testing self-reported food adequacy and income sufficiency as SEP variables in vision and eye health surveys in other locations, including assessing the acceptability, reliability and repeatability of each question.

Do we really want to know? The journey to implement empirical research recommendations in the ICRC's responses in Myanmar and Lebanon.

Efforts to reduce the gap between the research evidence base and humanitarian responses have focused on producing quality evidence and ensuring its use in decision-making. Yet, how evidence translates into field-level implementation is not well understood in humanitarian contexts. This study analysed how recommendations produced through academic research partnerships were implemented by the International Committee of the Red Cross (ICRC) in Lebanon and Myanmar. The methodology included: social network analysis to represent collective dynamics; document reviews to assess implementation; qualitative interviews to comprehend why actors engaged; and a critical appraisal of these combined results. The application of Extended Normalization Process Theory provided information on 'anticipation of constraints' (access to information, staff turnover, context specificity, and the need to engage as a cohesive group). Future research efforts should concentrate explicitly on identifying and tackling implementation barriers such as power imbalances and ethical dilemmas related to service delivery by humanitarian actors.

Prevalence of blindness and distance vision impairment in the Gambia across three decades of eye health programming.

BACKGROUND/AIMS: The 1986 Gambia National Eye Health Survey provided baseline data for a National Eye Health Programme. A second survey in 1996 evaluated changes in population eye health a decade later. We completed a third survey in 2019, to determine the current state of population eye health, considering service developments and demographic change. METHODS: We estimated prevalence and causes of vision impairment (VI) in a nationally representative population-based sample of adults 35 years and older. We used multistage cluster random sampling to sample 10 800 adults 35 and above in 360 clusters of 30. We measured monocular distance visual acuity (uncorrected and with available correction) using Peek Acuity. Participants with either eye uncorrected or presenting (with available correction) acuity <6/12 were retested with pinhole and refraction, and dilated exams were completed on all eyes by ophthalmologists using a direct ophthalmoscope, slit lamp and 90 D lens. RESULTS: We examined 9188 participants (response rate 83%). The 2013 census age-sex adjusted prevalence of blindness (presenting acuity<3/60 in better seeing eye) was 1.2% (95% CI 0.9 to 1.4) and of moderate or severe VI (MSVI,<6/18 to ≥3/60) was 8.9% (95% CI 9.1 to 9.7). Prevalence of all distance VI (<6/12) was 13.4% (12.4-14.4). Compared with 1996, the relative risk of blindness decreased (risk ratio 0.7, 95% CI 0.5 to 1.0) and MSVI increased (risk ratio 1.5, 95% CI 1.2 to 0.17). CONCLUSION: Significant progress has been made to reduce blindness and increase access to eye health across the Gambia, with further work is needed to decrease the risk of MSVI.

Prevalence of mental distress in adults with and without a history of tuberculosis in an urban Zambian community.

People with tuberculosis (TB) are susceptible to mental distress. Mental distress can be driven by biological and socio-economic factors including poverty. These factors can persist beyond TB treatment completion yet there is minimal evidence about the mental health of TB survivors. A cross-sectional TB prevalence survey of adults was conducted in an urban community in Zambia. Survey participants were administered the five-item Self Reporting Questionnaire (SRQ-5) mental health screening tool to measure mental distress. Associations between primary exposure (history of TB) and other co-variates with mental distress were investigated using logistic regression. Of 3,393 study participants, 120 were TB survivors (3.5%). The overall prevalence of mental distress (SRQ-5 ≥ 4) in the whole study population was 16.9% (95% CI 15.6%-18.1%). Previous TB history was not associated with mental distress (OR 1.20, 95% CI 0.75-1.92, p-value 1.66). Mental distress was associated with being female (OR 1.23 95% CI 1.00-1.51), older age (OR 1.71 95% CI 1.09-2.68) and alcohol abuse (OR 1.81 95% CI 1.19-2.76). Our findings show no association between a previous TB history and mental distress. However, approximately one in six people in the study population screened positive for mental distress.

Effective cataract surgical coverage in adults aged 50 years and older: estimates from population-based surveys in 55 countries.

BACKGROUND: Cataract is the leading cause of blindness globally. Effective cataract surgical coverage (eCSC) measures the number of people in a population who have been operated on for cataract, and had a good outcome, as a proportion of all people operated on or requiring surgery. Therefore, eCSC describes service access (ie, cataract surgical coverage, [CSC]) adjusted for quality. The 74th World Health Assembly endorsed a global target for eCSC of a 30-percentage point increase by 2030. To enable monitoring of progress towards this target, we analysed Rapid Assessment of Avoidable Blindness (RAAB) survey data to establish baseline estimates of eCSC and CSC. METHODS: In this secondary analysis, we used data from 148 RAAB surveys undertaken in 55 countries (2003-21) to calculate eCSC, CSC, and the relative quality gap (% difference between eCSC and CSC). Eligible studies were any version of the RAAB survey conducted since 2000 with individual participant survey data and census population data for people aged 50 years or older in the sampling area and permission from the study's principal investigator for use of data. We compared median eCSC between WHO regions and World Bank income strata and calculated the pooled risk difference and risk ratio comparing eCSC in men and women. FINDINGS: Country eCSC estimates ranged from 3·8% (95% CI 2·1-5·5) in Guinea Bissau, 2010, to 70·3% (95% CI 65·8-74·9) in Hungary, 2015, and the relative quality gap from 10·8% (CSC: 65·7%, eCSC: 58·6%) in Argentina, 2013, to 73·4% (CSC: 14·3%, eCSC: 3·8%) in Guinea Bissau, 2010. Median eCSC was highest among high-income countries (60·5% [IQR 55·6-65·4]; n=2 surveys; 2011-15) and lowest among low-income countries (14·8%; [IQR 8·3-20·7]; n=14 surveys; 2005-21). eCSC was higher in men than women (148 studies pooled risk difference 3·2% [95% CI 2·3-4·1] and pooled risk ratio of 1·20 [95% CI 1·15-1·25]). INTERPRETATION: eCSC varies widely between countries, increases with greater income level, and is higher in men. In pursuit of 2030 targets, many countries, particularly in lower-resource settings, should emphasise quality improvement before increasing access to surgery. Equity must be embedded in efforts to improve access to surgery, with a focus on underserved groups. FUNDING: Indigo Trust, Peek Vision, and Wellcome Trust.

Anxiety and depression in Guatemala: Sociodemographic characteristics and service access.

Epidemiological data on depression and anxiety in Guatemala is lacking. Using 2016 National Disability Survey data, we explored the sociodemographics of people with anxiety and/or depression and its heightened burden on access to key services. The survey (n = 13,073) used the Washington Group Extended Set to estimate disability prevalence, including anxiety and/or depression. A nested case-control study was included to explore the impact of disability on key life areas. Cases (indicating 'A lot of difficulty' or 'Cannot do' in one or more functional domain) and age-/sex-matched controls were administered a structured questionnaire. Multivariable logistic regression and heightened-burden analysis were conducted. Higher odds of anxiety and/or depression were found in participants who were 50+ (aOR 2.3, 1.8-3.1), female (aOR 1.8, 1.4-2.2), urban (aOR 1.5, 1.2-1.9), divorced/separated (aOR 2.0, 1.3-3.0), and widowed (aOR 1.6, 1.0-2.4), as well as those with impaired communication or cognition (aOR 17.6, 13.0-23.8), self-care (aOR 13.2, 8.5-20.5), walking (aOR 13.3, 9.7-18.3), hearing (aOR 8.5, 5.6-13.1), and vision (aOR 8.5, 6.1-11.8). Lower odds of anxiety and/or depression were found in participants with a university education (aOR 0.2, 0.5-0.9), and those living in the southeast (aOR 0.2, 0.1-0.3) or northeast (aOR 0.3, 0.2-0.4). Compared to people with impairments that were not depression and/or anxiety, people with depression and/or anxiety were less likely to receive a retirement pension (aOR 0.4, 0.2-0.8), and more likely to receive medication for depression/anxiety (aOR 4.1, 1.9-9.1), report a serious health problem (aOR 1.8, 1.3-2.5), and seek advice/treatment with a government health worker/health post (aOR 6.3, 1.0-39.2).

Childhood disability in rural Niger: a population-based assessment using the Key Informant Method.

BACKGROUND: Data on childhood disability is essential for planning health, education and other services. However, information is lacking in many low- and middle-income countries, including Niger. This study uses the Key Informant Method, an innovative and cost-effective strategy for generating population-based estimates of childhood disability, to estimate the prevalence and causes of moderate/severe impairments and disabling health conditions in children of school-going age (7-16 years) in the Kollo department of western Niger. METHODS: Community-based key informants were trained to identify children who were suspected of having the impairment types/health conditions included in this study. Children identified by key informants were visited by paediatricians and underwent an assessment for moderate/severe vision, hearing, physical and intellectual impairments, as well as epilepsy, albinism and emotional distress. RESULTS: Two thousand, five hundred sixty-one children were identified by key informants, of whom 2191 were visited by paediatricians (response rate = 85.6%). Overall, 597 children were determined to have an impairment/health condition, giving a prevalence of disability of 11.4 per 1000 children (10.6- 12.2). Intellectual impairment was most common (6.5 per 1000), followed by physical (4.9 per 1000) and hearing impairments (4.7 per 1000). Many children had never sought medical attention for their impairment/health condition, with health seeking ranging from 40.0% of children with visual impairment to 67.2% for children with physical impairments. CONCLUSION: The Key Informant Method enabled the identification of a large number of children with disabling impairments and health conditions in rural Niger, many of whom have unmet needs for health and other services.

Exploring the Use of Washington Group Questions to Identify People with Clinical Impairments Who Need Services including Assistive Products: Results from Five Population-Based Surveys.

This study analyses the use of the self-reported Washington Group (WG) question sets as a first stage screening to identify people with clinical impairments, service and assistive product (AP) referral needs using different cut-off levels in four functional domains (vision, hearing, mobility and cognition). Secondary data analysis was undertaken using population-based survey data from five countries, including one national survey (The Gambia) and four regional/district surveys (Cameroon, Chile, India and Turkey). In total 19,951 participants were sampled (range 538-9188 in individual studies). The WG question sets on functioning were completed for all participants alongside clinical impairment assessments/questionnaires. Using the WG "some/worse difficulty" cut-off identified people with mild/worse impairments with variable sensitivity (44-79%) and specificity (73-92%) in three of the domains. At least 64% and 60% of people with mild/worse impairments who required referral for surgical/medical and rehabilitation/AP services, respectively, self-reported "some/worse difficulty", and much fewer reported "a lot/worse difficulty." For moderate/worse impairment, both screening cut-offs improved identification of service/AP need, but a smaller proportion of people with need were identified. In conclusion, WG questions could be used as a first-stage screening option to identify people with impairment and referral needs, but only with moderate sensitivity and specificity.

"The weather is not good": exploring the menstrual health experiences of menstruators with and without disabilities in Vanuatu.

BACKGROUND: Menstrual health is essential for gender equality and achieving the sustainable development goals. Though currently lacking, understanding and addressing menstrual health and social related inequalities requires comparison of experiences between menstruators with and without disabilities. METHODS: We completed a mixed-methods population-based study of water, sanitation and hygiene, disability and menstrual health in TORBA and SANMA Provinces, Vanuatu. Methods included a census, nested case-control study, in-depth interviews (IDIs), focus group discussions (FGDs), PhotoVoice and structured observations. We undertook a population census of 11,000+ households and recruited 164 menstruators with and 169 without disabilities (aged 10-45) into a nested case-control study. 20 menstruators across both groups were selected for the qualitative component. FINDINGS: Menstruators with disabilities were five times (adjusted Odds Ratio [aOR] 5.5, 95% Confidence Interval 1.8 - 16.5) more likely to use different bathing facilities to others in the household, nearly twice as likely (1.8, 1.1 - 3.1) to miss social activities, and three times (3.0, 1.6 - 5.7) more likely to eat alone during menstruation. Menstrual restrictions were widespread for all, but collecting water and managing menstrual materials was harder for menstruators with disabilities, particularly those requiring caregivers' support. These factors negatively impacted menstruators with disabilities' comfort, safety and hygiene, yet they reported less interference of menstruation on participation. INTERPRETATION: Negative factors affecting all menstruators disproportionately impact those with disabilities, compounding existing inequalities. Menstruators with disabilities may have reported less interference because they are accustomed to greater participation restrictions than others. FUNDING: Australian Government's Water for Women fund and public donations.

A Systematic Review of the Proportion of Blindness in the Population 50 Years and Older from Total Population-Based Surveys of Blindness and Visual Impairment.

PURPOSE: Epidemiological data is essential for planning; however, all-age population-based surveys are resource intensive. Rapid Assessment of Cataract Surgical Services methodology was developed in India in 1995 and subsequently promoted by the World Health Organisation for use worldwide. The commonly used Rapid Assessment of Avoidable Blindness (RAAB) evolved from this in 2005, constraining surveys to populations aged 50 or more based on the report 'The Epidemiology of Blindness in Nepal' (SEVA, 1988), where 78.7% of blindness occurred in people aged 50+. The purpose of this study is to examine whether more recent total-population-based surveys continue to find a similar proportion of blindness in the population aged 50+. METHODS: A systematic literature review identified all population-based surveys of blindness published 1996-2017. Data extraction was undertaken by two independent researchers and compared. RESULTS: The proportions of blindness (presenting visual acuity (PVA) <3/60) and moderate/severe visual impairment (MSVI) (PVA <6/18-3/60) from total population-based surveys in people aged 50+ ranged from 90% (Mali, 1996) to 45.8% (South Korea, 2015); the mean proportions across all surveys were 73.1% (95% CI, 60.4-85.8%) for blindness, and 73.8% (95% CI, 54.8-92.8) for MSVI. No trend over time or association with GDP was identified. CONCLUSION: This systematic literature review supports the rationale for constraining surveys to the population aged 50+ as this will greatly reduce sample size but still include a high proportion of total cases of blindness; paucity of total population-based surveys highlights the ongoing need for RAAB in service planning internationally.

Eye health indicators for universal health coverage: results of a global expert prioritisation process.

INTRODUCTION: In its recent World Report on Vision, the WHO called for an updated approach to monitor eye health as part of universal health coverage (UHC). This project sought to develop a consensus among eye health experts from all world regions to produce a menu of indicators for countries to monitor eye health within UHC. METHODS: We reviewed the literature to create a long-list of indicators aligned to the conceptual framework for monitoring outlined in WHO's World Report on Vision. We recruited a panel of 72 global eye health experts (40% women) to participate in a two-round, online prioritisation exercise. Two-hundred indicators were presented in Round 1 and participants prioritised each on a 4-point Likert scale. The highest-ranked 95 were presented in Round 2 and were (1) scored against four criteria (feasible, actionable, reliable and internationally comparable) and (2) ranked according to their suitability as a 'core' indicator for collection by all countries. The top 30 indicators ranked by these two parameters were then used as the basis for the steering group to develop a final menu. RESULTS: The menu consists of 22 indicators, including 7 core indicators, that represent important concepts in eye health for 2020 and beyond, and are considered feasible, actionable, reliable and internationally comparable. CONCLUSION: We believe this list can inform the development of new national eye health monitoring frameworks, monitor progress on key challenges to eye health and be considered in broader UHC monitoring indices at national and international levels.

The Gambia National Eye Health Survey 2019: survey protocol.

Two national surveys of vision impairment and blindness were undertaken in The Gambia in 1986 and 1996. These provided data for the inception of The Gambia's National Eye Health Programme (NEHP) within the Ministry of Health and Social Welfare. There have been important developments in the eye health services provided by the NEHP in the last 20 years. At the same time, the population has also undergone major demographic changes that may have led to substantial changes in the burden of eye disease. We conducted a National Eye Health Survey of vision impairment, blindness and its comorbidities in adults in The Gambia in 2019. We examined a nationally representative population-based sample of adults 35 years and above to permit direct comparison with the data available from the previous surveys. Alongside a comprehensive vision and eye examination, the survey provides nationally representative data on important comorbidities in this population: diabetes, hypertension, obesity, hearing impairment, disability and mental health. Secondly, it estimates access to assistive technologies and eye health services. Thirdly, it is powered to allow a five-year follow up cohort study to measure the incidence and progression of eye disease.

Interrogating and Reflecting on Disability Prevalence Data Collected Using the Washington Group Tools: Results from Population-Based Surveys in Cameroon, Guatemala, India, Maldives, Nepal, Turkey and Vanuatu.

The Washington Group (WG) tools capture self-reported functional limitations, ranging from 6 domains in the Short Set (SS) to 11 in the Extended Set (ESF). Prevalence estimates can vary considerably on account of differences between modules and the different applications of them. We compare prevalence estimates by WG module, threshold, application and domain to explore these nuances and consider whether alternative combinations of questions may be valuable in reduced sets. We conducted secondary analyses of seven population-based surveys (analyses restricted to adults 18+) in Low- and Middle-Income Countries that used the WG tools. The prevalence estimates using the SS standard threshold (a lot of difficulty or higher in one or more domain) varied between 3.2% (95% Confidence Interval 2.9-3.6) in Vanuatu to 14.1% (12.2-16.2) in Turkey. The prevalence was higher using the ESF than the SS, and much higher (5 to 10-fold) using a wider threshold of "some" or greater difficulty. Two of the SS domains (communication, self-care) identified few additional individuals with functional limitations. An alternative SS replacing these domains with the psychosocial domains of anxiety and depression would identify more participants with functional limitations for the same number of items. The WG tools are valuable for collecting harmonised population data on disability. It is important that the impact on prevalence of use of different modules, thresholds and applications is recognised. An alternative SS may capture a greater proportion of people with functional domains without increasing the number of items.

"I'm scared to talk about it": exploring experiences of incontinence for people with and without disabilities in Vanuatu, using mixed methods.

BACKGROUND: Incontinence is the involuntary loss of urine and/or faeces. It is stigmatised and can reduce quality of life. People with incontinence require water, sanitation, hygiene (WASH) and incontinence products. People with disabilities are at risk of experiencing incontinence and may face challenges managing, however, minimal evidence exists. METHODS: This study aimed to complete a population-based study of disability in TORBA and SANMA Provinces, Vanuatu to quantify the prevalence and demographics of disability, experience of WASH access and incontinence for people with and without disabilities. We completed a survey, case-control study, in-depth interviews, structured observations and PhotoVoice. 179 people with disabilities and 148 people without disabilities completed the incontinence module in the case-control study. We applied purposeful sampling to select 27 people with and without a disability from the nested case-control, and 16 key informants for the qualitative study to further explore the impact of incontinence on people's lives. FINDINGS: People with disabilities were three times more likely to experience incontinence than people without disabilities (Adjusted Odds Ratio 3.3, 95% confidence interval 1.8 - 5.8). Challenges facing all people with incontinence were distance to latrines and lack of incontinence products. People with disabilities were less able to wash and participate in social activities. Less than 10% had assistive technologies; caregivers had no lifting devices. People experiencing incontinence did not disclose this to others, including medical professionals, who also did not raise the issue. INTERPRETATION: Inaccessible and inadequate WASH, lack of incontinence products and stigma increased isolation for all people with incontinence. Additionally, people with disabilities and caregivers faced discrimination and insufficient assistive technologies. This negatively affected their wellbeing and quality of life, and requires addressing. FUNDING: Australian Government's Water for Women Fund and public donations.

Are Nepal's water, sanitation and hygiene and menstrual hygiene policies and supporting documents inclusive of disability? A policy analysis.

PURPOSE: This study assesses the inclusion of disability in Nepal's policy and guidance relevant to water, sanitation and hygiene (WASH), and menstrual hygiene management (MHM) in comparison to gender. We investigated both policy formulation and implementation, using the Kavrepalanchok district as a case study. MATERIALS AND METHODS: We used the EquiFrame framework, adapted for disability and gender, and focusing on WASH and MHM. Ten Nepali policies and guidance documents were reviewed and scored for quality against the framework, which included 21 core concepts of human rights. We also interviewed key informants to consider the inclusion of disability in the implementation of MHM interventions. We applied stratified purpose sampling to 12 government officials and service providers working in Kathmandu and the Kavrepalanchock district; conducted in-depth interviews and analysed data thematically using Nvivo 11. RESULTS: Disability was inadequately covered within the policy documents, and MHM policy commitments for disability were almost non-existent. Participation of people with disabilities in policy development was limited; within Kavrepalanchok, policy commitments were not implemented as intended and disability service providers were unable to allocate government resources. Inadequate data on disability and MHM resulted in limited professional understanding of the issues, as service providers had no training. A narrow WASH infrastructure approach to improving MHM for people with disabilities was prioritised. MHM interventions were delivered in schools; these failed to reach children with disabilities who are often out of school. Finally, there were indications that some caregivers seek sterilisation for people with disabilities who are unable to manage menstruation independently. CONCLUSION: Though the Constitution of Nepal enshrines gender equality and disability inclusion, there are consistent gaps in attention to disability and MHM in policies and practice. These omit and exclude people with disabilities from MHM interventions. Investment is required to generate evidence on the MHM barriers faced by people with disabilities, which would then be drawn on to develop training on these issues for professionals to improve understanding. Subsequently, policy makers could include more concepts of human rights against disability in relevant policies and service providers could implement policy commitments as intended.

Estimating Need for Glasses and Hearing Aids in The Gambia: Results from a National Survey and Comparison of Clinical Impairment and Self-Report Assessment Approaches.

Few estimates are available of the need for assistive devices (ADs) in African settings. This study aimed to estimate population-level need for glasses and hearing aids in The Gambia based on (1) clinical impairment assessment, and (2) self-reported AD awareness, and explore the relationship between the two methods. The Gambia 2019 National Eye Health Survey is a nationally representative population-based sample of 9188 adults aged 35+ years. Participants underwent standardised clinical vision assessments including the need for glasses (distance and near). Approximately 25% of the sample underwent clinical assessment of hearing and hearing aid need. Data were also collected on self-reported awareness, need and access barriers to vision and hearing ADs. Overall, 5.6% of the study population needed distance glasses (95% CI 5.0-6.3), 45.9% (95% CI 44.2-47.5) needed near glasses and 25.5% (95% CI 22.2-29.2) needed hearing aids. Coverage for each AD was very low (<4%). The agreement between self-report and clinical impairment assessment for AD need was poor. In conclusion, there is high prevalence and very low coverage for distance glasses, near glasses and hearing aids in The Gambia. Self-report measures alone will not provide an accurate estimate of AD need.