Multidisciplinary visual rehabilitation in low- and middle-income countries: a systematic review.

OBJECTIVE: To systematically review the evidence for effectiveness of rehabilitation interventions in people who are visually impaired, living in low- and middle-income countries. METHODS: Fifteen databases and the grey literature were searched up until February 2020; papers were identified according to eligibility criteria, and assessed for risk of bias. Eligible studies were controlled trials (randomised or non-randomised) of rehabilitation interventions for blind or visually impaired adults or children from low- and middle-income countries. Possible outcomes included visual acuity, activities of daily living, safety, quality of life and psychological status. RESULTS: Fifteen eligible studies were identified from India, Turkey, Nigeria, Croatia and Iran. Six studies were randomised, seven were non-randomised trials, and in two the method of allocation was not clear. Participants were adults, children and both adults and children. Seven studies were small (n ≤ 65) and examined the effect of training programmes. Remaining studies compared the effect of low vision aids, economic rehabilitation, goalball, rehabilitation compliance and service delivery methods, including one large four-arm randomised trial (n = 436). Studies measured a variety of outcomes, and mostly showed a positive effect of interventions for pre- and post-intervention assessment, although between intervention group comparisons were often inconclusive. Overall, only four studies had a low risk of bias. CONCLUSIONS: A lack of high-quality evidence for rehabilitation interventions is a barrier to provision of low vision services in low- and middle-income countries. Future research should focus on establishing effectiveness and cost-effectiveness of devices and models of vision rehabilitation appropriate for low-resource settings.IMPLICATIONS FOR REHABILITATIONThe systematic review found a lack of high-quality evidence for rehabilitation interventions is a barrier to provision of low vision services in low- and middle-income countries.Consider how visual rehabilitation interventions which have been shown to be effective can be delivered by non-specialists.Ensure that service providers for people who are visually impaired are trained in recognising depression and anxiety and have pathways for referral to mental health services, as appropriate.

Economic inequality in malnutrition: a global systematic review and meta-analysis.

OBJECTIVE: To describe the evidence on global and regional economic inequality in malnutrition, and the associations between economic inequality and malnutrition. METHODS: We conducted a systematic review and meta-analysis. Between 1 November 2020 and 22 January 2021, we searched Medline, Embase, Global Health, Eldis, Web of Science and EBSCO Discovery Service. We contacted 39 experts and tracked citations. We included any study reporting a concentration index (CIX) relating economic status and nutritional status and any multilevel study reporting an association between economic inequality and nutritional status. Nutritional status was measured as stunting, wasting, anaemia, or overweight in children (<5 years), or underweight, overweight or obesity, or anaemia in adults (15-49 years). We had no study date or language restriction. Quality was assessed using the Appraisal Tool for Cross-Sectional Studies (AXIS tool). We mapped estimates and pooled them using multilevel random-effects meta-analyses. RESULTS: From 6185 results, 91 studies provided 426 CIX (>2.9 million people) and 47 associations (~3.9 million people). Stunting (CIX -0.15 (95% CI -0.19 to -0.11)) and wasting (-0.03 (95% CI -0.05 to -0.02)) are concentrated among poor households. Adult overweight and obesity is concentrated in wealthier households (0.08 (95% CI -0.00 to 0.17)), particularly in South Asia (0.26 (95% CI 0.19 to 0.34)), but not in Europe and Central Asia (-0.02 (95% CI -0.08 to 0.05)) or North America (-0.04 (95% CI -0.10 to 0.03)). We found no association between 0.1 increase in Gini coefficient and adult underweight (OR 1.03 (95% CI 0.94 to 1.12)) or overweight and obesity (0.92 (95% CI 0.80 to 1.05)). CONCLUSIONS: There is good evidence that the prevalence of malnutrition varies by levels of absolute economic status. Undernutrition is concentrated in poor households, whereas concentration of overweight and obesity by economic status depends on region, and we lack information on economic inequalities in anaemia and child overweight. In contrast, links between malnutrition and relative economic status are less clear and should not be assumed; robust evidence on causal pathways is needed. PROSPERO REGISTRATION NUMBER: CRD42020201572.