Disability and labour market participation among smallholder farmers in Western Kenya.

BACKGROUND: Despite the importance of labour market participation and the high number of people with disabilities in rural Africa who rely on subsistence agriculture to survive, very few studies have documented labour market outcomes among farmers with and without disabilities in Africa. OBJECTIVE: We examined how labour market participation differed by disability and other factors among smallholder farmers in Western Kenya. METHODS: We use cross-sectional data collected between January and April 2022 from sorghum farmers enrolled in a trial evaluating the impact of a programme designed to improve labour market participation among sorghum farmers in rural Western Kenya. Disability and Labour market outcomes were assessed using questions from the Washington Group /ILO Labor Force Survey Disability Module the ILO Labour Force Survey module respectively. Univariate and multiple regression analyses were conducted to identify socio-demographic characteristics and other related factors associated with labour market participation. RESULTS: Among 4459 participants, disability was reported by 20.3% of women and 12.3% of men. Labour market participation was reported by 77.1% and 81.3% of women and men, respectively. Adjusting for demographic confounders, having a disability was associated with a lower likelihood of labour market participation (odds ratio 0.59, 95% confidence interval, 0.42-0.83, P = 0.001). These findings were similar in a modified model that looked at functional difficulties separately from anxiety and depression. Women, older participants, and those who were dependent on others were also more likely not to report participation in the labour market. CONCLUSIONS: Increased recognition and understanding of functional limitations among smallholder farmers is vital for the success of economic empowerment programmes aimed at increasing labour market participation among the most vulnerable populations.

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.

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.

Vision impairment and self-reported anxiety and depression in older adults in Nigeria: evidence from a cross-sectional survey in Kogi State.

BACKGROUND: More than 2 billion people are thought to be living with some form of vision impairment worldwide. Yet relatively little is known about the wider impacts of vision loss on individual health and well-being, particularly in low- and middle-income countries (LMICs). This study estimated the associations between all-cause vision impairment and self-reported symptoms of anxiety and depression among older adults in Kogi State, Nigeria. METHODS: Individual eyes were examined according to the standard Rapid Assessment of Avoidable Blindness methodology, and anxiety and depression were assessed using the Washington Group Short Set on Functioning-Enhanced. The associations were estimated using multivariable logistic regression models, adding two- and three-way interaction terms to test whether these differed for gender subgroups and with age. RESULTS: Overall, symptoms of either anxiety or depression, or both, were worse among people with severe visual impairment or blindness compared with those with no impairment (OR=2.72, 95% CI 1.86 to 3.99). Higher levels of anxiety and/or depression were observed among men with severe visual impairment and blindness compared with women, and this gender gap appeared to widen as people got older. CONCLUSIONS: These findings suggest a substantial mental health burden among people with vision impairment in LMICs, particularly older men, underscoring the importance of targeted policies and programmes addressing the preventable causes of vision impairment and blindness.

Assessing the prevalence of refractive errors and accuracy of vision screening by schoolteachers in Liberia.

BACKGROUND: Evidence indicates that school-based vision screening by trained teachers is an effective way of identifying and addressing potential vision problems in schoolchildren. However, inconsistencies have been reported in both the testing methods and accuracy of the screeners. This study assessed the prevalence of refractive errors and accuracy of screening by teachers in Grand Kru County, Liberia. METHODS: We conducted a retrospective analysis of data from four schools where, in February 2019, children were screened for refractive errors by trained teachers and then re-examined by ophthalmic technicians. One row of five optotypes of the Snellen 6/9 (0.2 logMar) scale (tumbling E chart) was used at a distance of 3 m. The prevalence of visual impairment and associations with sex, age and school were explored. Sensitivity, specificity and predictive values were calculated. RESULTS: Data were available for 823 of 1095 eligible children with a mean age of 13.7 y (range 5-18) and male:female ratio of 1:0.8. Poor vision was identified in 24 (2.9%) children with no differences by either sex or age but small differences by school. Screening by teachers had a sensitivity of 0.25 (95% confidence interval [CI] 0.077 to 0.423) and a specificity of 0.996 (95% CI 0.992 to 1.000). Positive and negative predictive values were 0.667 (95% CI 0.359 to 0.975) and 0.978 (95% CI 0.968 to 0.988), respectively. The results were influenced by a high number of misclassifications in one of the four schools. CONCLUSIONS: Teachers can be trained to conduct vision screening tests on schoolchildren to an acceptable level of accuracy, but strong monitoring and quality assurance systems should be built into screening programmes from the onset. In settings like Liberia, where many children do not attend school regularly, screening programmes should extend to community platforms to reach children out of school.

Evidence on cataract in low- and middle-income countries: an updated review of reviews using the evidence gap maps approach.

In 2014, Sightsavers developed the first evidence gap map (EGM) to assess the extent and quality of review-level evidence on cataract relevant to low-and middle-income countries. The EGM identified 52 studies across five broad themes. This paper reports the update of the EGM conducted in 2021 and changes to the extent and quality of the evidence base. We updated the EGM using the exact process conducted to develop the original. Searches were run to 14 September 2021, and two independent reviewers selected eligible studies, critically appraised them and extracted data using the Supporting the Use of Research Evidence checklist. A summary quality assessment was shared with the authors for comments. Forty-six new reviews were identified, and the EGM now includes 98 reviews. The new reviews predominantly focus on treatment and risk factors. The overall methodological quality was found to be improved, with 13/46 reporting high confidence in findings. EGMs remain a useful tool for policy-makers to make informed decisions and periodic updates are important to assess changes and to refine the focus for future research. The EGM highlights significant disparity in the topics addressed by reviews, with health system interventions particularly neglected.

Measuring the impact of a training intervention for early childhood centre staff on child development outcomes: Findings from a cluster randomized control field trial in rural Malawi.

BACKGROUND: Evidence from low-income settings around early education interventions that can improve young children's development is sparse, particularly with regard to the most marginalized children. This study used a two-arm parallel cluster randomized control design to evaluate the impact of an adapted staff training programme on the developmental outcomes of children attending community-based early learning centres in Thyolo district, rural Malawi. METHODS: At baseline we randomly selected 48 centres, from each of which 20 children were randomly selected, although data from one centre was incomplete resulting in 932 children from 47 centres. Centres were randomly allocated to either the intervention or control arm. Twelve months later, follow-up data were collected from 44 centres. At baseline and endline, community-based childcare centre (CBCC) managers provided information about the centre, and parents/guardians provided information on the children, including the primary outcomes of age-standardized development scores in the language and social domains, measured using the Malawi Developmental Assessment Tool. Children in the bottom 2.5 percentile of either domain were considered to have a delay; a third outcome variable, Any Delay, was developed to indicate children with a delay in either or both domains. Centre-level mean scores were calculated, and linear regression models were constructed to assess differences between baseline and endline and between allocation groups. RESULTS: Analysis of the difference between baseline and endline measures in the allocation groups shows a non-significant reduction in delay associated with the study intervention across all domains. Adjustment for baseline characteristics within the CBCCs showed little impact on the magnitude of the observed effect, and the difference remained non-significant. CONCLUSIONS: Despite no observed differences between allocation groups, the data did indicate a positive change in the intervention groups in both domains, particularly language. Community-based early learning in Malawi holds tremendous potential for promoting inclusive development and learning.

Changes in Eye Health and Service Coverage in Nampula, Mozambique between 2011 and 2018.

PURPOSE: Globally, there are few examples of repeated eye health surveys to assess changes in prevalence and causes of visual impairment, and service coverage over time. Two separate, unlinked rapid assessments of avoidable blindness (RAAB) were conducted in Nampula province, Mozambique in 2011 and 2018. This paper reports the observed changes and examines how the trends differ for males and females. METHODS: Standard RAAB methodology was used in both studies. Two-stage cluster sampling was used to generate random samples of adults aged over 50 years. Participants underwent a simplified visual acuity (VA) exam, a lens exam and posterior segment exam using a direct ophthalmoscope for all subjects with presenting VA<6/18. Data were analysed using Stata and logistic regression models were developed to assess changes. RESULTS: The 2011 study enrolled 3,050 people and examined 96.9% (2,954 people). The 2018 survey enrolled 4,191 people and examined 95.8% (4,015 people). Age- and sex-adjusted estimates of blindness decreased from 6.2% in 2011 to 4.5% in 2018 (z = -2.21, p = .028). Cataract surgical coverage was higher among males in both surveys (13.4% among males vs 7.7% among females in 2011, and 40.0% among males vs 19.4% among females in 2018) and the gender disparity grew between surveys. CONCLUSION: Significant changes were observed in the eye health and service coverage between 2011 and 2018. Further improvements to services are required to improve access for women and people with moderate visual impairment.

Understanding patient health-seeking behaviour to optimise the uptake of cataract surgery in rural Kenya, Zambia and Uganda: findings from a multisite qualitative study.

BACKGROUND: Cataract is a major cause of visual impairment globally, affecting 15.2 million people who are blind, and another 78.8 million who have moderate or severe visual impairment. This study was designed to explore factors that influence the uptake of surgery offered to patients with operable cataract in a free-of-charge, community-based eye health programme. METHODS: Focus group discussions and in-depth interviews were conducted with patients and healthcare providers in rural Zambia, Kenya and Uganda during 2018-2019. We identified participants using purposive sampling. Thematic analysis was conducted using a combination of an inductive and deductive team-based approach. RESULTS: Participants consisted of 131 healthcare providers and 294 patients. Two-thirds of patients had been operated on for cataract. Two major themes emerged: (1) surgery enablers, including a desire to regain control of their lives, the positive testimonies of others, family support, as well as free surgery, medication and food; and (2) barriers to surgery, including cultural and social factors, as well as the inadequacies of the healthcare delivery system. CONCLUSIONS: Cultural, social and health system realities impact decisions made by patients about cataract surgery uptake. This study highlights the importance of demand segmentation and improving the quality of services, based on patients' expectations and needs, as strategies for increasing cataract surgery uptake.

Diabetic retinopathy service delivery and integration into the health system in Pakistan-Findings from a multicentre qualitative study.

This paper is based on qualitative research carried out in a diabetic retinopathy (DR) programme in three districts of Pakistan. It analyses the organisation and delivery of DR services and the extent to which the interventions resulted in a fully functioning integrated approach to DR care and treatment. Between January and April 2019, we conducted 14 focus group discussions and 37 in-depth interviews with 144 purposively selected participants: patients, lady health workers (LHWs) and health professionals. Findings suggest that integration of services was helpful in the prevention and management of DR. Through the efforts of LHWs and general practitioners, diabetic patients in the community became aware of the eye health issues related to uncontrolled diabetes. However, a number of systemic pressure points in the continuum of care seem to have limited the impact of the integration. Some components of the intervention, such as a patient tracking system and reinforced interdepartmental links, show great promise and need to be sustained. The results of this study point to the need for action to ensure inclusion of DR on the list of local health departments' priority conditions, greater provision of closer-to-community services, such as mobile clinics. Future interventions will need to consider the complexity of adding diabetic retinopathy to an already heavy workload for the LHWs.

Eye Health Service Uptake among People with Visual Impairment and Other Functional Difficulties in Bangladesh: A Cross-Sectional Study with Short-Term Follow Up.

People with visual impairments are disproportionately likely to also have other impairments. However, little is known about whether these other impairments affect access to eye health services. This study among cataract and refractive error patients in four districts in Bangladesh explores the relationship between self-reported difficulties in hearing, mobility, self-care, communication and cognition domains, eye health service uptake, and location of initial eye health assessment. Cataract and refractive errors were diagnosed through ophthalmic clinical assessment, and the Washington Group Short Set (WG-SS) was used to ascertain difficulties in other functional domains. Univariate and multivariate analyses were used to examine the relationship between functional difficulties and uptake of cataract and refractive error services. We found that people with self-reported functional difficulties were less likely to take up refractive error services compared to people with same need but with no functional difficulties, and that they were more than twice as likely to access surgical services after attending an outreach camp compared with a hospital facility. Since a high proportion of people attending eye health assessment services have difficulties in a range of functional domains, strategies to improve the uptake of hospital-based health services are urgently required.

Task-shifting eye care to ophthalmic community health officers (OCHO) in Sierra Leone: A qualitative study.

BACKGROUND: Preventing visual impairment due to avoidable causes has been a long-standing global priority. Of all blindness in Sierra Leone, 91.5% is estimated to be avoidable and 58.2% treatable, however there are only 6 ophthalmologists for the whole country. Task-shifting has been suggested as a strategy to address this issue and a training intervention was developed to create a cadre of community-based staff known as Ophthalmic Community Health Officers (OCHOs). This qualitative study aimed to explore the experiences of OCHOs, their relationship with other eye health workers, and how they interact with the wider health system, in order to provide recommendations for the design and delivery of future task shifting strategies. METHODS: Between April and May 2018, we conducted semi-structured interviews with 42 participants including: OCHOs (n = 13), traditional ophthalmic staff (n = 17) and other stakeholders from the districts (n = 6), training institution staff (n = 4) and MOH headquarters (n = 2). We identified participants using purposive sampling. Interviews were audio-recorded, transcribed, and thematically analysed. We draw largely on in-depth interviews but complement the analysis with evidence from a document review. RESULTS: In Sierra Leone, the roll-out of the OCHO programme presented a mixed picture. OCHOs participating in the study expressed a strong commitment to their new role. However, policy changes proposed to clearly demarcate roles and responsibilities and institutionalise the cadre in the civil service were not implemented, resulting in the posting of some staff at an inappropriate level, dissatisfaction with the OCHO certification, and lack of opportunities for advancement and training. These challenges reflect structural weaknesses in the health system that undermine a cohesive implementation of eye health initiatives at the primary health care level in Sierra Leone. CONCLUSIONS: Task-shifting has the potential to improve provision in under-resourced specialities such as eye health. However, the success of this approach will be contingent upon the development of a robust and supportive health policy environment.

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.

School-based vision screening in Quetta, Pakistan: a qualitative study of experiences of teachers and eye care providers.

BACKGROUND: Visual impairment in children is a significant public health problem affecting millions of children globally. Many eye problems experienced by children can be easily diagnosed and treated. We conducted a qualitative study with teachers and optometrists involved in a school-based vision screening programme in Quetta district of Pakistan to explore their experiences of training, vision screening and referrals and to identify factors impacting on the effectiveness of the programme. METHODS: Between April 2018 and June 2018, we conducted semi-structured in-depth interviews with 14 teachers from eight purposefully selected schools with high rates of inaccurate (false positive) referrals. Interviews were also conducted with three optometrists from a not-for profit private eye care hospital that had trained the teachers. Interviews were audio recorded and professionally transcribed. NVIVO software version 12 was used to code and thematically analyze the data. RESULTS: Findings suggest that the importance of school-based vision screening was well understood and appreciated by the teachers and optometrists. Most participants felt that there was a strong level of support for the vision screening programme within the participating schools. However, there were a number of operational issues undermining the quality of screening. Eight teachers felt that the duration of the training was insufficient; the training was rushed; six teachers said that the procedures were not sufficiently explained, and the teachers had no time to practice. The screening protocol was not always followed by the teachers. Additionally, many teachers reported being overburdened with other work, which affected both their levels of participation in the training and the time they spent on the screening. CONCLUSIONS: School-based vision screening by teachers is a cost-effective strategy to detect and treat children's vision impairment early on. In the programme reviewed here however, a significant number of teachers over referred children to ophthalmic services, overwhelming their capacity and undermining the efficiency of the approach. To maximise the effectiveness and efficiency of school-based screening, future initiatives should give sufficient attention to the duration of the teacher training, experience of trainers, support supervision, refresher trainings, regular use of the screening guidelines, and the workload and motivation of those trained.

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.

Strengths and weaknesses of eye care services in sub-Saharan Africa: a meta-synthesis of eye health system assessments.

BACKGROUND: In sub-Saharan Africa (SSA), the delivery of eye care services continues to be undermined by health systems performance bottlenecks. There is a growing focus by partners in the sector on the analysis of the different components of eye care within the wider health system context to diagnose and manage interactions in ways that achieve more effective improvements. However, there has been no attempt to date to systematically synthesize these studies. In this study, we conducted a meta-synthesis of eye health system assessments to gain a more comprehensive understanding of the current systems and how they can be strengthened across different SSA contexts. METHODS: We conducted a comprehensive search for eye health system assessment reports using global and regional websites of the WHO and other organizations supporting eye care in sub-Saharan Africa. A range of online databases with no language restrictions (PubMed, EMBASE, MEDLINE, PsycINFO and CINAHL) were searched for peer-reviewed publications referring to eye health system assessment (EHSA) or eye care service assessment tool (ECSAT). Assessments were included if they used the ECSAT or EHSA tool; were conducted in sub-Saharan Africa; and had been completed with full reports available in the public domain by January 15, 2019. A combination of framework and thematic syntheses was used. RESULTS: Our search strategies yielded a total of 12 assessments conducted in nine countries using the ECSAT/EHSA tool in Sub-Saharan Africa. Eight assessments met our inclusion criteria: four were from West Africa, two from East Africa and two from Southern Africa. Across the eight countries, findings show considerable progress and improvements in the areas of governance, organisation, financing, provision, and coverage of eye care. However, several systemwide weaknesses were found to continue to impede quality eye health service planning and delivery across the countries included in this review. CONCLUSIONS: These findings highlight the need for national governments and iNGOs to invest in conducting and wider use of these assessments. Such analyses are particularly useful in building links between different system elements and in finding innovative, more flexible solutions and partnerships - needed to address avoidable vision loss in resource poor settings.

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.

Estimated prevalence of disability and developmental delay among preschool children in rural Malawi: Findings from "Tikule Limodzi," a cross-sectional survey.

BACKGROUND: Early childhood development (ECD) is a critical stage in children's lives, influencing future development and social integration. ECD research among children with disability and developmental delay in low- and middle-income countries is limited but crucial to inform planning and delivery of inclusive services. This study is the first to measure and compare the prevalence of disability and developmental delay among children attending preschool centres in rural Malawi. METHODS: A cross-sectional survey was conducted in 48 preschool centres in Thyolo district, Malawi. Data were collected from parents or guardians of 20 children per centre. Disability was ascertained using the Washington Group/UNICEF Child Functioning Module. Child development was measured using the language and social domains of the Malawi Development Assessment Tool. RESULTS: A total of 960 children were enrolled; 935 (97.4%) children were assessed for disability and 933 (97.2%) for developmental delay; 100 (10.7%) children were identified as having a disability. The prevalence of disability was higher among children 5+ years (n = 60; 29.3%) than children 2-4 years (n = 40; 5.5%); 109 of 933 (11.7%) children were classified as having developmental delay, 41 (4.4%) in "language" and 77 (8·3%) in "social" domains. CONCLUSIONS: This study found that disability and developmental delays are common among preschool children in Malawi. It is one of the first to measure disability and delay among children in a preschool setting in Africa.