Self-management interventions for quality of life in adults with visual impairment.

Abstract

Rationale: Visual impairment is a major health concern that predominantly impacts older adults due to age-related ocular diseases. Visual impairment affects more than 2200 million people worldwide and may lead to functional and psychological decline, emphasizing the need for effective self-management interventions. Self-management interventions aim to enhance individuals' abilities to manage their condition, maintain activities of daily living, and improve overall well-being.

Objectives: To assess the effects of self-management interventions on quality of life in adults with visual impairment compared with inactive or active (usual care) control interventions.

Search methods: We searched CENTRAL, MEDLINE, Embase, two other databases, and two trial registries, together with reference checking and contact with study authors to identify studies that are included in the review. The latest search date was on 19 May 2024.

Eligibility criteria: We included parallel-group randomized controlled trials (RCTs) comparing multifaceted self-management interventions in adults with acquired visual impairment (including dual sensory impairment).

Outcomes: Outcomes assessed were overall and subscores of health-related quality of life (HRQoL) and vision-related quality of life (VRQoL) scores at the end of follow-up, adverse events during the study period, and vision-related living performance measures at the end of follow-up.

Risk of bias: We assessed the risk of bias for three outcomes reported in a summary of findings table using the Cochrane RoB 2 tool.

Synthesis methods: We synthesized results for each outcome using meta-analysis where possible, by calculating standardized mean difference (SMD) or mean difference (MD) with 95% confidence interval (CI) for continuous outcomes and risk ratio (RR) with 95% CIs for dichotomous outcomes. Where this was not possible due to the nature of the data, we provided a narrative summary of the results. We used GRADE to assess certainty of evidence for prespecified outcomes.

Included studies: We included 20 parallel-group RCTs that enrolled 3151 participants. The size of studies ranged from 30 to 323 participants with a median of 153 participants. Studies were conducted in Asia (two studies), Australia (two), Europe (six), and North America (10) in academic medical centers, hospitals, low-vision clinics, private practice, rehabilitation centers, and Veterans Affairs medical facilities. The participants were older adults with a mean age across the included studies ranging from 60 to 84 years. The mean logarithm of the minimum angle of resolution (logMAR) visual acuity ranged from 0.15 to 1.11. Age-related macular degeneration was the predominant cause of low vision in 15 studies. We did not identify any eligible studies for adults with dual sensory impairment. One study was funded by industry, whereas others received a research grant or support from a non-profit organization or foundation. Multifaceted self-management interventions included in this review were diverse. The control group was placed on a wait list, while other active controls included usual care, optical aids, or low-vision rehabilitation.

Synthesis of results: We rated the overall risk of bias of included studies as low or some concerns. The meta-analysis revealed consistent findings across different outcomes and comparisons. For HRQoL, evidence suggests that self-management intervention may result in little to no difference in HRQoL (change score: SMD -0.09, 95% CI -0.33 to 0.15; I² = 46%; 3 studies, 568 participants; final value: SMD -0.15, 95% CI -0.38 to 0.08; I² = 31%; 3 studies, 459 participants; low-certainty evidence). This finding remained consistent regardless of whether wait list or active control was the comparator. For VRQoL, multifaceted self-management interventions may result in little to no difference in VRQoL change score compared to active control (SMD -0.12, 95% CI -0.33 to 0.10; I² = 48%; 4 studies, 733 participants; low-certainty evidence). The evidence from six studies by final values suggests that self-management intervention may not improve VRQoL compared to control treatment in the longer-term (6 to 24 months) (SMD -0.01, 95% CI -0.14 to 0.13; I² = 0%; 6 studies, 864 participants; low-certainty evidence). The conclusion was unchanged, irrespective of the comparator used. We judged the certainty of evidence for both HRQoL and VRQoL as low according to GRADE criteria, downgrading one level for imprecision and one level for unexplained heterogeneity. For harms, self-management interventions may not affect the risk of adverse events (RR 1.14, 95% CI 0.78 to 1.66; I² = 0%; 2 studies, 255 participants; low-certainty evidence). Of four studies that reported adverse events, three studies observed no treatment-related adverse events. One study referred 12 (34%) participants to the general medical practitioner for depressive symptoms in the intervention group compared with seven (22%) participants in the wait list comparison group.

Authors' conclusions: In this review, we found low-certainty evidence that multifaceted self-management interventions have little or no effects on improving HRQoL and VRQoL for adults with visual impairment. Research is needed to develop more sensitive measures of quality of life and to assess the benefit of such interventions across a broader demographic, including different stages of vision impairment and people with dual-sensory impairment.

Funding: Cochrane Eyes and Vision US Project is supported by grant UG1EY020522, National Eye Institute, National Institutes of Health.

Registration: Protocol available via doi.org/10.1002/14651858.CD015790.