1055924

research-article2021
JVI0010.1177/02646196211055924British Journal of Visual ImpairmentXulu-Kasaba and Kalinda

BJVI
Research Article

British Journal of Visual Impairment

Prevalence of blindness and its

1­–15
© The Author(s) 2021
Article reuse guidelines:
major causes in sub-Saharan sagepub.com/journals-permissions
DOI: 10.1177/02646196211055924
https://doi.org/10.1177/02646196211055924
Africa in 2020: A systematic journals.sagepub.com/home/jvi

review and meta-analysis

Zamadonda Nokuthula Xulu-Kasaba

University of KwaZulu-Natal, South Africa

Chester Kalinda
University of Global Health Equity (UGHE), Bill and Joyce Cummings Institute of Global Health, Kigali, Rwanda;
University of KwaZulu-Natal, South Africa

Abstract
Background: Global studies show that the prevalence of visual impairment and blindness
continued to rise despite the implementation of strategies outlined in the Global Action Plan, aimed
at reducing these by the year 2020. Vision impairment impacts negatively on one’s independence,
opportunities, and quality of life. Therefore, knowledge of the prevalence, and the major causes of
blindness impairment in any population, is vital in designing strategies to address this public health
challenge.
Methods: Literature mapping evidence of vision impairment was searched for on PubMed,
Google Scholar, and EBSCOhost databases MEDLINE, Health Source: Nursing/Academic Edition,
Health Source – Consumer Edition, CINAHL, and Academic Search Complete. Studies that
were searched for included peer-reviewed and grey literature published in English from various
countries in sub-Saharan Africa (SSA).
Results: Only 77 studies with 191,173 participants, contributing data from 26 countries within
SSA, met the inclusion criteria for the final review. The overall pooled prevalence estimate (PPE)
of blindness from the selected studies was 10% (95% confidence interval [CI]: 8.0% – 11.0%).
West Africa and East Africa had the highest prevalence. The identified leading causes of blindness
were cataracts (46%; 95% CI: 40% – 52%), followed by glaucoma (14%; 95% CI: 11% – 18%).
There was a high level of heterogeneity in most pooled estimates (I2 ˃ 80%, p < .001).
Conclusion: The prevalence of blindness in SSA has increased in all four regions with most
cases being avoidable. Policymakers should prioritise blindness prevention programmes, ensure
enabling health systems, and provide the necessary resources towards reducing blindness in SSA.

Keywords
Avoidable blindness, blindness, cataract, diabetic retinopathy, eye health, glaucoma, sub-Saharan
Africa, trachoma

Corresponding author:
Zamadonda Nokuthula Xulu-Kasaba, Department of Optometry, College of Health Sciences, University of KwaZulu-
Natal, Private Bag X 54001, Durban, 4000, South Africa.
Email: XuluKasabaZ@ukzn.ac.za
2 British Journal of Visual Impairment 00(0)

Background
According to the World Health Organization (WHO, 2021), blindness is a visual impairment con-
dition where the presenting visual acuity is worse than 3/60, or the visual field less than 10 degrees
from the point of fixation, as outlined in the eleventh International Classification of Diseases (ICD-
11). A recent study by Bourne et al. (2017) suggests that 36 million people are blind globally,
indicating that blindness is still a serious problem. Of greater concern is the fact that 75% of blind-
ness and visual impairment are preventable or avoidable (WHO, 2019a).
Various campaigns and initiatives have been launched to address and eliminate avoidable blind-
ness. The ‘VISION 2020: Right to Sight’ campaign by WHO aimed at eliminating avoidable blind-
ness by at least 25% by the year 2020 (WHO, 2013). Furthermore, the Global Action Plan (GAP)
sought to ensure access to rehabilitation for those with visual impairment, including blindness, as
one of its goals (The International Agency for the Prevention of Blindness [IAPB], 2013).
Recent reports affirm that low-to-middle-income countries (LMICs) have four times the blind
population as that found in high-income countries, with females more affected than males (Bourne
et al., 2017). Emerging evidence indicates that almost 90% of the blind live in LMICs (Bourne
et al., 2017) where they face challenges of poverty, which is directly related to blindness (Naidoo,
2007). Sub-Saharan Africa (SSA) is one of the poorest regions in the world (The World Bank,
2019), with the most rapid population growth (The World Bank, 2018). The likely increase in
population will ensure an increase in blindness (Flaxman et al., 2017; WHO, 2020), which will
continue to pose a public health threat, further highlighting the need for the urgent management of
this health scourge.
Following the WHO request for population-based studies to determine the actual prevalence of
blindness and its causes in SSA (Resnikoff et al., 2004), many primary studies have been con-
ducted in recent years. In managing blindness, identifying its causes is a key factor that will assist
in ultimately eliminating the condition.
This systematic review aimed to ascertain the prevalence of blindness and its major causes in
SSA. Of further interest, this article aimed to accurately measure their distribution and extent,
through meta-analysis. The outcome is aimed to assist policymakers align blindness prevention
programmes and eye health resource allocation to be aptly worked into universal health coverage
programmes, as per WHO recommendation (WHO, 2019a). Results will also allow directorates to
evaluate the success of any blindness prevention programmes that may have been initiated in the
different countries within SSA.

Methodology
Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) rec-
ommended for its rigour in literature search (Joanna Briggs Institute, 2015), the study identified
articles for inclusion in the final meta-analysis.
Following the Joanna Briggs methodology (Joanna Briggs Institute, 2015), Arksey and O’Malley’s
five-step framework was used to identify published and unpublished studies reporting on the preva-
lence and causes of visual impairment and blindness in SSA. Various databases were searched and
quality assessment and meta-analysis of all included studies were conducted at the end. Studies were
selected following the process outlined below and shown on a PRISMA chart diagram.

Research question
The research questions that the study aimed to answer was:
Xulu-Kasaba and Kalinda 3

Table 1. Population concept context (PCC) framework.

Population Studies on Humans of all ages

Concept Visual impairment and blindness (using the highest causes of blindness globally
– cataract, uncorrected refractive error, age-related macular degeneration,
glaucoma, diabetic retinopathy, corneal opacity, and trachoma)
Context Sub-South Africa in the period 2010–2020

1. What is the prevalence of blindness in SSA?

2. What are the major causes of blindness in the SSA region?

The Population Concept Context (PCC) (Joanna Briggs Institute, 2015) model in Table 1 was used
in this study.
SSA defines the geographical area of 46 countries South of the Sahara desert on the African
continent (‘Part III’, 2014). In this study, these countries have been grouped into four regions
named Central Africa, East Africa, Southern Africa, and West Africa (Figure 1). The number of
studies that were obtained from each country within its geographical region is shown in Figure 1.

Study search
Searching for studies was guided by inclusion criteria that included only primary studies on
humans, on eye health and eye diseases and with a greater emphasis on the global leading causes
of blindness (WHO, 2021). Inclusion was limited to quantitative studies written in English as
prevalence information needed to be extracted and the language needed to be understood by the
authors. All studies had to adhere to the time frame 1 January 2010 to 30 June 2020.
Databases that were searched for studies included PubMed, Google Scholar, and EBSCOhost
databases: Health Source: Nursing/Academic Edition, Health Source – Consumer Edition,
CINAHL, and Academic Search Complete. Quantitative studies and mixed-method studies quan-
tifying the prevalence of visual impairment and blindness in a given population were included in
this study.
Keywords used in the searches were ‘Prevalence of visual impairment OR Prevalence of
Blindness OR Prevalence of Avoidable blindness OR Epidemiology of Visual Impairment OR
Vision Impairment’. To improve study identification, synonyms, and types of visual conditions,
also known as Medical Subject Heading (MeSH) terms were used to identify relevant articles.
These included the leading global causes of blindness and visual impairment, namely
Uncorrected Refractive Error (URE), cataract, glaucoma, diabetic retinopathy, corneal opacity,
trachoma, and macular degeneration (WHO, 2021). Boolean terms were used too where ‘OR’
assisted in increasing the study search and ‘AND’ was used to specify certain concepts such as
the time frame.
During the initial search, the study context was excluded to ensure that studies that had not
specified their countries in SSA were not excluded. It was, however, later included in title, abstract,
and full-article screening. Articles retrieved from database searches were stored in a new library,
created on EndNote X7. Where full articles were not readily available, the University of KwaZulu-
Natal (UKZN) library assisted with obtaining those articles. In addition to this extensive search, a
manual search was conducted to find articles that might not have emerged in the database search,
such as those that were unpublished and kept in repositories such as the Rapid Assessment of
Avoidable Blindness (RAAB) Repository (2020).
4 British Journal of Visual Impairment 00(0)

Figure 1. Map showing countries, regions, and the number of studies obtained from each country with
the specific regions of sub-Saharan Africa.

From the Endnote folder, duplicates were removed before title screening of all articles using a
previously piloted and standardised tool. On completion of title screening, a trained co-screener
was enrolled in the study to assist with abstract and full-article screening, also using piloted stand-
ardised tools.

Final article selection

Studies that satisfied the inclusion and exclusion criteria after full-article screening were included
in the processes, data extraction, and quality appraisal. The PRISMA chart (Figure 2) below shows
the entire process of article selection.

Data charting
Data extraction followed article selection, and this was aligned with the aim of this study. The tool
used here was piloted using five similar studies from countries outside SSA. After it was modified
(Supplementary file sheet S1), information on blindness prevalence and its different causes and
distribution was charted.

Collating, summarizing, and reporting of results

After charting, data were transferred to a Microsoft Excel document, cleaned, and arranged
(increasing order and geographical regions) for meta-analysis using MetaXL.
Xulu-Kasaba and Kalinda 5

Figure 2. Prisma flow diagram.

Quality appraisal
It is advisable for systematic reviews to include a quality appraisal section to ensure that there was
no bias in study selection and further to assess the integrity of included studies (Liberati et al.,
2009). This final step is recommended to ascertain the quality of the methods used in included
primary studies that use a quantitative, qualitative, or mixed-methods study design (Pluye et al.,
2011). Using a validated tool, the 2018 revised Mixed Method Appraisal Tool (MMAT) (Hong
et al., 2018), 55 articles with a clear methodology section were assessed. Following the two screen-
ing questions, each included study was critically evaluated by one of the authors and an independ-
ent reviewer. As the latest tool discourages allocating actual scores, the scoring guideline of the
2011 MMAT (Pluye et al., 2011) tool was applied. Each of the five questions was weighted equally
with a score of 20% if the criteria had been met. Essentially, a study could score 0% if none of the
criteria had been met, 20% where one of the five criteria had been met, up to 100% if all five cri-
teria had been met. Thereafter, the scores of the assessors were added, and the study allocated the
average of the two scores.
The overall quality of included studies was categorised as 0%–20% for studies of low quality,
50%–60% for average studies, and 80%–100% for studies of high quality. (Supplementary file
sheets S1 and S2).

Data analysis
To analyse the data obtained, MetaXL 3.1 (http://www.epigear.com/) was used to pool prevalence
from each study (Barendregt & Doi, 2016; Barendregt et al., 2013). Pooled prevalence estimates
6 British Journal of Visual Impairment 00(0)

(PPEs) and their 95% confidence intervals (CI) were estimated using the random effect model.
PPEs were calculated for all studies focusing on blindness. Furthermore, we determined the PPE
of blindness for those above the age of 50 to align with the inclusion age for Rapid Assessment of
Avoidable Blindness (RAAB Repository, 2016) which is for those who are 50 years and older. We
also determined the PPE for the sub-categories of aetiology that were observed to lead to blindness
as reported in the selected studies. The level of heterogeneity was evaluated using Cochran’s Q
statistic and I2. Heterogeneity was classified as low, moderate, and high degree of heterogeneity if
the I2 values of 25%, 50%, and 75%, respectively, were obtained (Higgins et al., 2003). Publication
bias was assessed using funnel plots. Furthermore, the symmetry of the Doi plot was assessed
using the Luis Furuya–Kanamori (LFK) index (Barendregt & Doi, 2016). LFK index values within
±1, exceeding ±1 but within ±2, and exceeding ±2 were considered as having no asymmetry,
minor asymmetry, and major asymmetry, respectively (Barendregt & Doi, 2016). Potential sources
of heterogeneity were further assessed by arranging the studies in a subgroup of geographical
regions (Central, East, West, and Southern Africa).

Results
Characteristics of included studies
A total of 2999 studies were identified through the electronic search of databases. A further 34
additional studies were added after searching through the RAAB database and unpublished mate-
rial. After screening for their suitability, 77 studies containing quantitative data were included for
the final meta-analysis (Figure 2). Among the studies selected for the final analysis, one was con-
ducted in Central Africa (Ukety & Lewallen, 2015), 28 in East Africa, 16 in Southern Africa, and
32 were from West Africa. The quality index for the retained article ranged from 40% to 90%,
averaged between two assessors (Supplementary file S1 and S2). Sub-categories of aetiology
showed the most significant causes of blindness to be cataract, glaucoma, diabetic retinopathy, and
trachoma. Uncorrected Refractive Error (URE), macular degeneration, onchocerciasis, corneal
conditions and other causes of blindness were the least significant causes of blindness. Other
causes of blindness identified from studies but not quantified included trauma, injuries, and corneal
complications following cataract extraction surgery.

Pooled prevalence estimates and heterogeneity analyses

Seventy-seven studies reported the overall prevalence of blindness. Among these, 1% (n = 1) was
from Central Africa, 36% (n = 28) were from East Africa, 21% (n = 16) were from Southern Africa,
and 42% (n = 32) were from West Africa. Furthermore, cataracts (reported in 48 studies), glaucoma
(reported in 41 studies), diabetic retinopathy (reported in 9 studies), and trachoma (reported in 26
studies) were observed as the major causes of blindness. The overall prevalence of blindness was
10% (95% CI: 8%–11%). (Figure 3). West Africa and East Africa had the highest prevalence of
14% (95% CI: 11%–18%) and 8% (95% CI: 6%–11%), respectively, while Southern Africa had
5.0% (95% CI: 3%–7%). A paucity of data and an insufficient number of studies from Central
Africa made it difficult to estimate the regional prevalence of blindness.
The overall estimated pooled prevalence of blindness among people aged 50 and above was
45% (95%: 40%–50%). The results also showed that PPE of blindness among males above the
age of 50 was 39% (95%: 33%–45%) while PPE of blindness among women in the same age
category was 50% (95% CI: 43%–58%) (Supplementary file S3 Figure 1). Furthermore, when
blindness for people above the age of 50 was stratified by region and gender, the PPE of blindness
Xulu-Kasaba and Kalinda 7

Figure 3. Random effect model of pooled prevalence estimate of blindness in sub-Saharan Africa.

was highest among females in East Africa (52%; 95% CI: 49%–54%) and least among those from
West Africa (45.0%; 95% CI: 40%–50%). For males, PPE was highest among those from East
Africa (34%; 95% CI: 22%–47% and least among males from West Africa (29%; 95% CI: 17%–
41%) (Figure 4).
8 British Journal of Visual Impairment 00(0)

Figure 4. Random effect model of pooled prevalence estimate of blindness among people aged 50 and
above in sub-Saharan Africa.

Among the identified leading causes of blindness, cataracts were the most prevalent (46%; 95%
CI: 40%–52%), followed by glaucoma (14%; 95% CI: 11%–18%) and diabetic retinopathy (14%;
95% CI: 11%–17%). The least cause of blindness was trachoma (2%; 95% CI: 1%–3%) (Table 2).
Xulu-Kasaba and Kalinda 9

Table 2. Estimated pooled prevalence of blindness and causes of blindness in sub-Saharan Africa.

Variable Region Sample Size Cases PPE (%) 95% CI I2 (%)

Overall Sub-Saharan Africa 191,173 9180 10 8.0–11 99
blindness Central Africa 3561 75 1 03 99
East Africa 67,722 2917 8 6–11 99
Southern Africa 40,451 1508 5 3–7 99
West Africa 83,168 4743 14 11–17 99
Cataract Sub-Saharan Africa 6082 2759 46 40–52 96
East Africa 2593 1029 43 32–54 97
Southern Africa 1346 634 48 37–59 94
West Africa 2068 1042 48 38–58 96
Glaucoma Sub-Saharan Africa 18,900 1488 14 11–18 94
East Africa 1388 237 16 12–20 76
Southern Africa 1230 230 20 15–25 79
West Africa 16,207 1014 10 7–14 94
Trachoma Sub-Saharan Africa 4025 192 5 3–8 93
East Africa 1636 86 6 1–13 96
Southern Africa 553 22 4 3–6 0
West Africa 1761 82 5 3–6 93
DR–blindness Sub-Saharan Africa 1207 22 2 1–3 45
East Africa 890 17 2 1–4 42
Southern Africa 145 4 4 0–13 79
West Africa 172 1

PPE: pooled prevalence estimate; DR: diabetic retinopathy.

In terms of regional distribution of these causes of blindness, cataracts were more prevalent in
Southern Africa (48%; 95% CI: 37%–59%) and West Africa (48%; 95% CI: 38%–58%). Blindness
due to diabetic retinopathy was more prevalent in Southern Africa (20%; 95% CI: 15%–25%) and
least prevalent in East Africa (16%; 95% CI: 12%–20%). Furthermore, glaucoma was more preva-
lent in Southern Africa (20%; 95% CI: 15%–25%) compared to the other two regions (Supplementary
file S3 Figure S2, S3, S4, S5). Data from Central Africa was insufficient to estimate the PPE of the
identified leading causes of blindness. A high level of heterogeneity in most pooled estimates was
observed (I2 > 80%) and this could not be reduced with subgroup analysis of age category and geo-
graphical regions. Assessment of the funnel plot and Doi plot ruled out significant publication bias
(Supplementary files S5 and S6: Figure S0, S1, S2, S3 S4).

Discussion
This study focused on blindness, defined as a visual impairment where presenting visual acuity
is worse than 3/60 and/or visual fields are 10 degrees or less. It was noted, however, that none
of the included studies assessed visual fields to include limitation thereof as a cause of blind-
ness; all the included studies used visual acuity and pathology to determine blindness in their
populations. As blindness leads to reduced economic activity, a lower likelihood of education,
and reduced Disability Adjusted Life Years (DALYs), the prevalence thereof poses a severe
concern to SSA and the continent. The prevalence of blindness obtained in the current study is
comparable to that which has been reported in other LMICs (Casson, et al., 2007; Murthy et al.,
10 British Journal of Visual Impairment 00(0)

2001). The current study observed a higher PPE compared with that which was observed in
2010 by Naidoo et al. (2014), but lower than the 15% reported by Pascolini et al in 2011
(Pascolini & Mariotti, 2012). The prevalence of blindness observed in this study might be due
to an increase in RAAB studies in the specified period (RAAB Repository, 2020), which had
many participants aged 50 and over. According to Pascolini et al in 2011 (Pascolini & Mariotti,
2012), people above the age of 50 contribute over 80% of the global prevalence of blindness,
another reason that could have resulted in the greater prevalence in our study as compared with
the previous study in the same region. This suggests that among other activities that health
directorates of non-communicable diseases in SSA should focus on, eye health programmes
should also be emphasised in an attempt to reduce the accelerating burden of blindness in an
ageing population (Cheng et al., 2020).
A significant 45% of the blind were those over the age of 50 with females outnumbering
males. While Eastern and Southern regions of SSA contributed lower prevalences of blindness
for people aged 50 and above, West Africa had the highest population of this age group.
Considering that this study is only looking at blindness with no consideration of uncorrected
refractive error due to presbyopia, it is alarming that the prevalence of blindness for this age
group is elevated to the current level. Various studies have previously expressed the fact that the
ageing population will place a strain on the public health system as a significant increase in non-
communicable diseases would be seen (Cheng et al., 2020; Whillans & Nazroo, 2016). Other
studies have also indicated that a growing elderly population may negatively affect the economy
of a country as their dependency on the state increases expenditure overall (GBD 2015 Mortality
and Causes of Death Collaborators, 2016; GBD 2015 Risk Factors Collaborators, 2015; Orlická,
2015). Henceforth, managing the blindness should be attended to urgently as this significant
prevalence of blindness in those aged 50 and older has dire effects on health systems and the
already ailing resources in SSA.
The study also observed inter-regional variations in the prevalence of blindness within SSA.
Due to a lack of studies in Central Africa, the prevalence estimate observed was obtained from a
single study (Ukety & Lewallen, 2015). This under-representation may create a false implication
of successful intervention in blindness prevention. Previous reviews that have attempted to quan-
tify the burden of blindness in Africa also observed a lack of data from Central Africa. The paucity
of studies in the Central African region was previously flagged in systematic reviews conducted for
the periods 1990–2010 and 2015 (Bourne et al., 2017; Naidoo et al., 2014). The continued lack of
important data on blindness from Central Africa is likely to mask the reality of vision impairment
and its management in this poorly resourced region. Being one of the poorest regions on the poor-
est continent in the world (Giovetti, 2019; SOS-USA, n.d.; The World Bank, 2019), it is imperative
that more studies be conducted in Central Africa to obtain improved evidence, and ensure adequate
planning and management of blindness in that part of Africa.
The prevalence of blindness observed in Southern Africa is lower than that which has been
observed in previous studies (Bourne et al., 2017). The observed reduction in prevalence for both
males and females may be due to increased activities focusing on the management of blindness in
Southern Africa. The training and use of Ophthalmology trained Medical/Clinical Officers (OMO/
OCO), as well as holding cataract extraction camps, has improved cataract surgery rate (CSR)
immensely in South Africa. Further up in Zambia, some Ophthalmic Nurses have been trained in
cataract extraction (Bozzani et al., 2014) with a similar programme also initiated in Malawi (Kalua,
2018; Lewallen et al., 2012). These initiatives have assisted in reducing blindness in the Southern
region. Support should be given to other member countries to assess their vision impairment status
to give a holistic picture of blindness management in Africa.
Xulu-Kasaba and Kalinda 11

Our study observed that the West and East Africa regions had the highest levels of blindness in
SSA. Previous studies have also shown that the burden of blindness in these two regions rank
among the highest in the world (Flaxman et al., 2017). This may be due to insufficient investment
in blindness prevention. There is an urgent need to prioritise blindness prevention efforts in these
regions by scaling up practitioner training. An increase in human resources for eye health (HReH)
should be prioritised in these regions as the shortage of these professionals contributes to the
increased burden of disease (Bogunjoko et al., 2017).
In our study, the causes of blindness were assessed with pooled prevalences ranging from
14% to 46%, with cataracts being the most prevalent. Unavoidable causes of blindness like
oculocutaneous albinism emerged in some studies (Xulu-Kasaba et al., 2020). Most blindness
in the current study was avoidable, similar to previous studies (Mohammadi et al., 2017; WHO,
2019b, 2021). The study participants from our pooled studies were drawn from poor communi-
ties in SSA where people may not pay attention to sun protection. It is likely that if these com-
munities took precautions, the incidence of cataracts would have been reduced, resulting in a
lower resultant prevalence. In addition to the environment, the CSR is significantly low in
LMICs than they are in High-Income countries (“Cataract Surgical Rates,” 2017). For instance,
countries such as Ivory Coast and Nigeria in West Africa were found to have the lowest abso-
lute values for CSR, despite the latter having the highest population in SSA (“Cataract Surgical
Rates,” 2017). Eastern and Central Africa also fared among the lowest CSR in this poorest
WHO region. Reasons for low CSR are largely due to low HReH rates, lack of required equip-
ment, low awareness and education levels, a shortage and maldistribution of HReH, and inac-
cessible health care facilities, as most are within urban areas. Addressing these critical issues is
therefore pivotal to the improvement of CSR and will go a long way towards alleviating these
populations of blindness due to cataracts.
Other causes of blindness observed were diabetic retinopathy and glaucoma. Glaucoma is also
largely avoidable. Although studies included did not specify the type of glaucoma causing blind-
ness within SSA, open-angle glaucoma is most common among Africans (Cook, 2009; Kyari et al.,
2013). In SSA, there has been an emerging upwards rise of non-communicable diseases such as
diabetes (Bigna & Noubiap, 2019). Better management of diabetes as a whole is needed for the
prevalence of diabetic retinopathy (DR) to be reduced. Early fundus screening has been proposed
to reduce the scourge of avoidable blindness through diabetic retinopathy and glaucoma (Fang
et al., 2020; Piyasena et al., 2019; Zikhali & Xulu-Kasaba, 2020). With limited resources and most
people being seen at local primary health facilities, DR screening at this level in SSA would go a
long way in reducing the prevalence of this blinding condition within Africa. With support by rel-
evant policies and guidelines that will enable earlier screening at Primary Health Level, unneces-
sary blindness would be avoided as DR and glaucoma would be diagnosed early before subsequent
disease progression and vision loss.
Trachoma, an irreversible condition caused by the bacteria Chlamydia trachomatis, is the
leading cause of infectious and avoidable blindness in the world (WHO, 2020). Although it has
been eradicated in the Western world and Europe, it is still prevalent in Africa. Trachoma, also
referred to as ‘disease for the rural poor’ (Lietman & Fry, 2001), highlights serious inequities in
resources, access, and utilisation of health care in poor countries. Elimination initiatives such as
the SAFE (surgery, administering of azithromycin, face washing, and ensuring a satisfactory
environment) were developed to eradicate trachoma by the year 2020 (Lavett et al., 2013). Due
to lack of development in sanitation and basic resources, this goal remains unmet and trachoma
resurgence ensues repeatedly. There is a need to strengthen Trachoma control activities such as
community-based interventions (CBIs) which may involve the use of existing structures and
education of health workers especially in areas where it remains prevalent. The use of Community
12 British Journal of Visual Impairment 00(0)

Health Workers (CHWs) could be pivotal in disseminating health education around general
hygiene and sanitation (Bhutta et al., 2014). These strategies would have a positive impact on the
reduction of trachoma.

Limitations of this study

The presence of a few francophone countries within SSA means that there might have been some
studies in French, which would have been excluded in this review. Further to this, no studies were
found to include visual field assessment. The prevalence of blindness might have been underesti-
mated due to the omission of blindness according to this definition in the included studies. A fur-
ther bias might have been introduced by the fact that approximately 50% of the studies were
RAAB studies, which are population studies aimed at those over the age of 50. In light of this, the
age-analysis might have been biased, leading to a limitation in the actual age-related blindness
prevalence in SSA.

Conclusion
Blindness is still a serious problem in SSA, worsened by the increasing ageing population of those
above age 50. Albeit largely avoidable, blindness continues to reduce DALYs and exacerbate pov-
erty in all the regions of SSA. More studies need to be conducted in the central region of SSA to
provide sufficient data for analysis. Training of health workers, screening programmes in primary
health settings, health education, and a basic hygiene infrastructure should be prioritised in resource
allocation to reduce the prevalence of blindness in SSA. The directorates of Health should look to
strengthening health systems at community levels and addressing inequity in SSA to manage
avoidable blindness successfully.

Acknowledgements
This article forms part of a PhD project undertaken at University of KwaZulu-Natal. Support services were
provided by UKZN library services and artwork by Mr Media X.

Author contributions
ZXK conceptualised the study, conducted article search, screened eligible studies, and extracted data. CK
analysed the data, conducted the meta-analysis, and interpreted results. ZXK prepared the initial manuscript,
and both authors reviewed and contributed to the final manuscript.

Availability of data and materials

All data generated from this study will be included in the published systematic review article and will also be
available on request.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publica-
tion of this article: The University Capacity Development Programme section of the University of KwaZulu-
Natal funded this study.

ORCID iD
Zamadonda Nokuthula Xulu-Kasaba https://orcid.org/0000-0003-2729-8639
Xulu-Kasaba and Kalinda 13

Supplemental material
Supplemental material for this article is available online.

References
Barendregt, J. J., & Doi, S. A. (2016). MetaXL user guide (Version 5.3). EpiGear International.
Barendregt, J. J., Doi, S. A., Lee, Y. Y., Norman, R. E., & Vos, T. (2013). Meta-analysis of prevalence.
Journal of Epidemiology and Community Health, 67(11), 974–978.
Bhutta, Z. A., Sommerfeld, J., Lassi, Z. S., Salam, R. A., & Das, J. K. (2014). Global burden, distribution,
and interventions for infectious diseases of poverty. Infectious Diseases of Poverty, 3, 21–21. https://doi.
org/10.1186/2049-9957-3-21
Bigna, J. J., & Noubiap, J. J. (2019). The rising burden of non-communicable diseases in sub-Saharan Africa.
The Lancet Global Health, 7(10), e1295–e1296. https://doi.org/10.1016/S2214-109X(19)30370-5
Bogunjoko, T. J., Hassan, A. O., Akanbi, T. B., Ashaye, A., & Akinye, A. (2017). Analysis of human resources
for eye health in Ogun State of Nigeria: Progress towards vision 2020. British Journal of Medicine &
Medical Research, 19(10), 1–9.
Bourne, R., Flaxman, S., Braithwaite, T., Cicinelli, M. V., Das, A., & Jonas, J. B. . . . Vision Loss Expert
Group. (2017). Magnitude, temporal trends, and projections of the global prevalence of blindness and
distance and near vision impairment: A systematic review and meta-analysis. The Lancet Global Health,
5(9), e888–e897. https://doi.org/10.1016/S2214-109X(17)30293-0
Bozzani, F., Griffiths, U., Blanchet, K., & Schmidt, E. (2014). Health systems analysis of eye care services in
Zambia: Evaluating progress towards VISION 2020 goals. BMC Health Services Research, 14, Article
94. https://doi.org/10.1186/1472-6963-14-94
Casson, R. J., Newland, H. S., Muecke, J., McGovern, S., Durkin, S., Sullivan, T., . . .Aung, T. (2007).
Prevalence and causes of visual impairment in rural Myanmar: The Meiktila Eye Study. Ophthalmology,
114(12), 2302–2308. https://doi.org/10.1016/j.ophtha.2007.02.004
Cataract surgical rates. (2017). Community Eye Health Journal, 30(100). https://www.cehjournal.org/wp-
content/uploads/7.pdf
Cheng, X., Yang, Y., Schwebel, D. C., Liu, Z., Li, L., Cheng, P., . . .Hu, G. (2020). Population ageing and
mortality during 1990-2017: A global decomposition analysis. PLOS Medicine, 17(6), Article e1003138.
https://doi.org/10.1371/journal.pmed.1003138
Cook, C. (2009). Glaucoma in Africa size of the problem and possible solutions. Journal of Glaucoma, 18,
124–128.
Fang, Y., Cheng, J., Zhu, L., Xiao, M., & Sun, X. (2020). Evaluation of routine health examination for
screening primary open angle glaucoma in eastern China: A hospital-based cross-sectional study. Risk
Management and Healthcare Policy, 13, 883–892. https://doi.org/10.2147/RMHP.S258524
Flaxman, S. R., Bourne, R. R. A., Resnikoff, S., Ackland, P., Braithwaite, T., Cicinelli, M. V., . . .Zheng,
Y. (2017). Global causes of blindness and distance vision impairment 1990–2020: A systematic review
and meta-analysis. The Lancet Global Health, 5(12), e1221–e1234. https://doi.org/10.1016/S2214-
109X(17)30393-5
GBD 2015 Mortality and Causes of Death Collaborators. (2016). Global, regional, and national life expec-
tancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: A system-
atic analysis for the Global Burden of Disease Study 2015. The Lancet, 388, 1459–1544.
GBD 2015 Risk Factors Collaborators. (2015). Global, regional, and national comparative risk assessment
of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015:
A systematic analysis for the Global Burden of Disease Study. The Lancet, 388(10053), 1659–1724.
https://doi.org/10.1016/S0140-6736(16)31679-8
Giovetti, O. (2019). The world’s 10 poorest countries. Concern Worldwide US. https://www.concernusa.org/
story/worlds-poorest-countries/
Higgins, J. P., Thompson, S. G., Deeks, J. J., & Altman, D. G. (2003). Measuring inconsistency in meta-
analyses. British Medical Journal, 327(7414), 557–560.
14 British Journal of Visual Impairment 00(0)

Hong, Q. N. P. P., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M., Dagenais, P., . . .Vedel, I. M. (2018).
Mixed methods appraisal tool (MMAT, Version 2018). https://www.nccmt.ca/knowledge-repositories/
search/232%20(accessed%20May%202017)
The International Agency for the Prevention of Blindness. (2013). Global action plan 2014-2019. https://
www.iapb.org/learn/resources/who-global-action-plan-2014-2019/
Joanna Briggs Institute. (2015). The Joanna Briggs Institute reviewers’ manual 2015 methodology for JBI
scoping reviews.
Kalua, K. (2018). How to create a balanced eye team: An example from Malawi. Community Eye Health,
31(102), 46–46.
Kyari, F., Abdull, M. M., Bastawrous, A., Gilbert, C. E., & Faal, H. (2013). Epidemiology of glaucoma in sub-
Saharan Africa: Prevalence, incidence and risk factors. Middle East African Journal of Ophthalmology,
20(2), 111–125. https://doi.org/10.4103/0974-9233.110605
Lavett, D. K., Lansingh, V. C., Carter, M. J., Eckert, K. A., & Silva, J. C. (2013). Will the SAFE strategy
be sufficient to eliminate trachoma by 2020? Puzzlements and possible solutions. The Scientific World
Journal, 2013, Article 648106. https://doi.org/10.1155/2013/648106
Lewallen, S., Etya’ale, D., Kello, A. B., & Courtright, P. (2012). Non-physician cataract surgeons in sub-
Saharan Africa: Situation analysis. Tropical Medicine & International Health, 17(11), 1405–1408.
https://doi.org/10.1111/j.1365-3156.2012.03084.x
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gøtzsche, P. C., Ioannidis, J. P. A., . . .Moher, D. (2009).
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate
health care interventions: Explanation and elaboration. Journal of Clinical Epidemiology, 62(10), e1–
e34. https://doi.org/10.1016/j.jclinepi.2009.06.006
Lietman, T., & Fry, A. (2001). Can we eliminate trachoma? British Journal of Ophthalmology, 85(4), Article
385. https://doi.org/10.1136/bjo.85.4.385
Mohammadi, S.-F., Saeedi-Anari, G., Ashrafi, E., Mohammadi, S.-M., Farzadfar, F., Lashay, A., & Hashemi, H.
(2017). Prevalence and major causes of visual impairment in Iranian adults: A systematic review. Middle
East African Journal of Ophthalmology, 24(3), 148–155. https://doi.org/10.4103/meajo.MEAJO_168_16
Murthy, G. V., Gupta, S., Ellwein, L. B., Munoz, S. R., Bachani, D., & Dada, V. K. (2001). A population-
based eye survey of older adults in a rural district of Rajasthan: I. Central vision impairment, blindness,
and cataract surgery. Ophthalmology, 108(4), 679–685. https://doi.org/10.1016/s0161-6420(00)00579-0
Naidoo, K. (2007). Poverty and blindness in Africa. Clinical and Experimental Optometry, 90(6), 415–421.
Naidoo, K., Gichuhi, S., Basanez, M. G., Flaxman, S. R., Jonas, J. B., Keeffe, J., . . .Bourne, R. R. (2014).
Prevalence and causes of vision loss in sub-Saharan Africa: 1990-2010. British Journal of Ophthalmology,
98(5), 612–618. https://doi.org/10.1136/bjophthalmol-2013-304081
Orlická, E. (2015). Impact of population ageing and elderly poverty on macroeconomic aggregates. Procedia
Economics and Finance, 30, 598–605. https://doi.org/10.1016/S2212-5671(15)01272-1
Part III: Sub-Saharan Africa. (2014, May 11). FinancialTimes. https://www.ft.com/content/b139d3d9-ea61-
34b6-8f96-6fb14f09c22d
Pascolini, D., & Mariotti, S. P. (2012). Global estimates of visual impairment: 2010. The British Journal of
Ophthalmology, 96(5), 614–618. https://doi.org/10.1136/bjophthalmol-2011-300539
Piyasena, M. M. P. N., Murthy, G. V. S., Yip, J. L. Y., Gilbert, C., Peto, T., Gordon, I., . . .Kamalakannan, S.
(2019). Correction to: Systematic review and meta-analysis of diagnostic accuracy of detection of any
level of diabetic retinopathy using digital retinal imaging. Systematic Reviews, 8(1), Article 106. https://
doi.org/10.1186/s13643-019-1023-7
Pluye, P., Robert, E., Cargo, M., Bartlett, G., O’Cathain, A., Griffiths, F., . . .Rousseau, M. C. (2011).
Mixed method appraisal tool 2011. http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/
fetch/84371689/MMAT%202011%20criteria%20and%20tutorial%202011-06-29updated2014.08.21.pdf
Rapid Assessment for Avoidable Blindness Repository. (2016). What is RAAB. http://raabdata.info/about-the-
raab-repository/what-is-raab/
Rapid Assessment for Avoidable Blindness Repository. (2020). Rapid Assessment of Avoidable Blindness
(RAAB) repository. http://raabdata.info/
Xulu-Kasaba and Kalinda 15

Resnikoff, S., Pascolini, D., Etya’ale, D., Kocur, I., Pararajasegaram, R., Pokharel, G. P., & Mariotti, S. P.
(2004). Global data on visual impairment in the year 2002. Bulletin of the World Health Organization,
82(11), 844–851. https://doi.org//S0042-96862004001100009
SOS-USA. (n.d.). On the poorest continent, the plight of children is dramatic. https://www.sos-usa.org/
about-us/where-we-work/africa/poverty-in-africa#:~:text=Africa%20is%20considered%20the%20
poorest,society%2C%20their%20children%20and%20women
Ukety, T., & Lewallen, S. (2015). Rapid assessment of avoidable blindness in democratic Republic of Congo.
RAAB Repository. http://raabdata.info/
Whillans, J., & Nazroo, J. (2016). Social inequality and visual impairment in older people. The Journals of
Gerontology: Series B, 73(3), 532–542. https://doi.org/10.1093/geronb/gbv163
The World Bank. (2018). Understanding poverty. https://www.worldbank.org/en/understanding-poverty
The World Bank. (2019). State of the poor: where are the poor and where are the poorest?. https://www.
worldbank.org/content/dam/Worldbank/document/State_of_the_poor_paper_April17.pdf
World Health Organization. (2013). Universal eye health: A global action plan 2014-2019.
World Health Organization. (2019a). WHO launches first World report on vision. https://www.who.int/news-
room/detail/08-10-2019-who-launches-first-world-report-on-vision
World Health Organization. (2019b). World report on vision. http://apps.who.int/iris
World Health Organization. (2020). Trachoma. https://www.who.int/news-room/fact-sheets/detail/trachoma
World Health Organization. (2021). Blindness and vision impairment. https://www.who.int/news-room/fact-
sheets/detail/blindness-and-visual-impairment
Xulu-Kasaba, Z., Mashige, K., Mthembu, M., Mazibuko, N., Mabunda, N., Randeree, A., & Parsad, A.
(2020). A profile of patients presenting at a low vision clinic in a resource-limited setting. African Vision
and Eye Health, 79, Article a500. https://doi.org/10.4102/aveh.v79i1.500
Zikhali, T., & Xulu-Kasaba, Z. (2020). Mapping evidence on the management of diabetic retinopathy using
teleophthalmology to complement human resources for eye health: A scoping review protocol. Global
Journal of Health Science, 12(7), 11–19. https://doi.org/10.5539/gjhs.v12n7p11