Situation analysis of rehabilitation services for persons with disabilities in Bangladesh: identifying service gaps and scopes for improvement

Exploring access to social protection by persons with disabilities in Bangladesh

BACKGROUND

Social protection programs have played a significant role in ensuring that persons with disabilities (PWD) in low- and middle-income countries have access to basic livelihoods. However, there is a lack of research examining the extent of social protection program coverage for PWD and the factors influencing their inclusion. This study aimed to explore the extent of PWD's inclusion in social protection programs in Bangladesh and the factors influencing their inclusion in these programs.

METHODS

We analyzed data from the 2021 National Household Survey on Persons with Disabilities in Bangladesh. The outcome variable considered was PWD's inclusion in social protection programs (yes, no) to receive support, as well as the timing of inclusion in the social protection program (non-inclusion (0), inclusion within 0-6 months of the survey (1), and inclusion more than 6 months before the survey (2)). Explanatory variables included factors at the individual, household, and community levels. A multilevel multinomial logistic regression model was used to explore the associations between the outcome variable and explanatory variables, with respondents categorized into two groups based on age (children (0 to <18) and adults and older (18-95 years)).

RESULTS

Data from a total of 4,293 PWD were analyzed, with a mean age of 41.4 years; 59% of the respondents were male. Approximately 37.7% (95% CI, 36.0-39.6) of the total respondents reported inclusion in social protection programs within 0-6 months of the survey, rising to 47.4% (95% CI, 45.6-49.2) for support received more than 6 months before the survey. "Disability allowances (69.0%) were the most common type of social protection program that PWD reported being included in, followed by old age allowances (16.3%) and assistance through the VGD/VGF programs (6.8%). Among children aged <18 years, the likelihood of inclusion in social protection programs was higher for those with multiple disabilities. In contrast, for PWD aged 18 years and older, inclusion in social protection programs was lower among those with mental illness, hearing disabilities, and intellectual disabilities. The likelihood of inclusion in social protection programs was higher for older, unmarried, widowed, divorced, or separated PWD. Conversely, PWD from wealthier households and those residing in the Dhaka division had a lower likelihood of being included in social protection programs.

CONCLUSION

The findings of this study underscore the urgent need for more comprehensive and inclusive social protection policies and programs to support the well-being of PWD in Bangladesh. Since disability grants are the primary source of social protection for this group, it is crucial to expand coverage and increase the amount of financial support provided.

Sustainable Model of Early Intervention and Telerehabilitation for Children With Cerebral Palsy in Rural Bangladesh: The SMART-CP Randomized Clinical Trial

Importance

Access to early intervention and rehabilitation services among children with cerebral palsy (CP) remains limited in Bangladesh, which demands an innovative and sustainable service delivery model.

Objective

To evaluate the effectiveness of the Sustainable Model of Early Intervention and Telerehabilitation for Children With CP (SMART-CP) model compared with usual care in improving access to and utilization of early diagnosis, early intervention, and rehabilitation services in rural Bangladesh.

Design, Setting, and Participants

This was a 2-arm cluster randomized clinical trial, with 8 clusters (ie, subdistricts) randomly allocated to the intervention (SMART-CP model) or control arm. The setting was in Sirajganj, Bangladesh, and included children with CP 18 years or younger. Outcomes were measured at 0 and 12 months, and an intention-to-treat analysis was conducted. Data were analyzed from December 2023 to May 2024.

Interventions

The SMART-CP model comprised (1) a rural referral network involving key informants and caregiver peer groups (called mPower or mothers' power), (2) subdistrict level SMART-CP centers, and (3) telerehabilitation services. Children in the intervention arm received weekly goal-directed therapy, mPower group meetings every 2 weeks, and monthly telerehabilitation sessions.

Main Outcomes and Measures

The primary outcome was whether a child with CP accessed any form of rehabilitation services, with secondary outcomes analyzed as hypothesis generating.

Results

Overall, 968 children with CP (mean [SD] age, 7.9 [4.9] years; 581 male [60.0%]) were enrolled, with 500 in the intervention arm and 468 in the control arm. Between baseline and endline, rehabilitation services uptake significantly increased in the intervention arm (70.2% [351 of 500] vs 99.4% [497 of 500]), compared with the control arm (63.9% [299 of 468] vs 68.2% [319 of 468]; P <.001). Children in the intervention arm were 1.5 times more likely to access rehabilitation than the control arm. Secondary analyses suggested that the intervention arm also facilitated early CP diagnosis (mean [SD] diagnosis time, 2.0 [2.0] years vs 3.8 [3.3] years; Cohen d = -0.7) and initiation of rehabilitation (mean [SD] rehabilitation time, 1.8 [1.8] years vs 3.6 [2.4] years; Cohen d = -0.9). Additionally, higher therapy session counts (mean [SD] session counts, 23.4 [31.7] vs 4.3 [20.8]; Cohen d = 0.7), increased assistive device utilization (20.8% [104 of 500] vs 3.0% [14 of 468]; risk ratio, 0.82; 95% CI, 0.78-0.86; P < .001), and lower out-of-pocket expenditure per month (mean [SD] expenditure, $1.5 [$1.6] vs $2.9 [$5.1]; Cohen d = -0.4) were found in the intervention arm. No significant difference in clinical outcomes and mortality rates was observed between the intervention and control groups.

Conclusions and Relevance

Results of this cluster randomized clinical trial reveal that the SMART-CP model improved access to and utilization of early diagnosis and intervention services for children with CP in rural Bangladesh. This model holds promise for global scalability.

Trial Registration

ANZCTR Trial Identifier: ACTRN12622000396729.

Development and Beta Validation of an mHealth-Based Hearing Screener (SRESHT) for Young Children in Resource-Limited Countries: Pilot Validation Study

BACKGROUND

The prevalence of hearing loss in infants in India varies between 4 and 5 per 1000. Objective-based otoacoustic emissions and auditory brainstem response have been used in high-income countries for establishing early hearing screening and intervention programs. Nevertheless, the use of objective screening tests in low- and middle-income countries (LMICs) such as India is not feasible. Mobile health (mHealth) solutions have been demonstrated to be a viable option for hearing screening in LMICs.

OBJECTIVE

This study aims to develop and beta-validate an affordable hearing screener for children younger than 6 years of age to identify moderately severe or higher degrees of hearing loss.

METHODS

In phase 1, a mHealth-based hearing screener (SRESHT) was developed using a single board computer with wireless commercial headphones and speakers as transducers, which were calibrated according to the standard procedure. Three subjective hearing screening modules were conceptualized and developed for different age groups: (1) behavioral observation audiometry-screening for infants aged from 0 to 1 year; (2) speech spectrum awareness task-screening for children 1 to 3 years old; and (3) speech recognition task-screening for children 3 to 6 years old. Different auditory stimuli for the screening modules were generated and suitability was assessed: (1) noisemakers, animal sounds, and environmental sounds for infants (birth to 1 year old); (2) animal sounds and nonsense syllables for children (1 to 3 years old); and (3) eighteen picturable spondee words for children (3 to 6 years old). In phase 2, the SRESHT screener was beta-validated in children aged below 6 years to establish the agreement between SRESHT modules and the gold-standard procedure in identifying moderately severe and higher degrees of hearing loss.

RESULTS

Off-the-shelf commercial speakers and headphones were selected and calibrated. On comparison of stimuli for behavioral observation audiometry on 15 children, Noisemaker stimuli were found suitable based on the average minimum response levels. On comparison of different stimuli for speech spectrum awareness task on 15 children, animal sounds were found to be suitable. On familiarity check of 18 spondee words for speech recognition task among 20 children, 12 spondee words had the eligibility cutoff (85%) and a presentation level of 5 dB SL (re-pure tone threshold) was sufficient to achieve 80% psychometric function. In phase 2, a total of 55 children aged 0 to 6 years (31 normal hearing and 24 hearing impairment) underwent SRESHT screening for beta validation. Cohen κ indicated that the overall SRESHT screener had a very good agreement (κ=0.82) with gold-standard audiometric screening for identifying moderately severe and higher degrees of hearing loss.

CONCLUSIONS

The development and beta validation of the SRESHT screener using the selected auditory stimuli showed that the stimuli were suitable for screening children.

Integration of rehabilitation services in primary, secondary, and tertiary levels of health care systems in low- and middle-income countries: a scoping review

PURPOSE

Integration is a concept that seeks to strengthen the delivery of services to ensure people receive a continuum of care across the health system. We conducted a scoping review to explore how rehabilitation services have been integrated into health systems in low- and middle- income countries (LMICs).

MATERIALS AND METHODS

We conducted a scoping review using Valentijn's Rainbow Model of Integrated Care (RMIC) as an organising framework. The key enablers of integration of rehabilitation were extracted, charted and summarised according to the RMIC framework.

RESULTS

Of 4667 articles identified, 44 met inclusion criteria. Most studies focused on rehabilitation within secondary and tertiary level facilities, and described service models incorporating clinical, professional and functional integration characteristics. The geographical and clinical scope of rehabilitation models that demonstrate elements of integration from LMICs is limited.

CONCLUSION

The key enablers identified highlight the important role of responsive multidisciplinary care plans, and interdisciplinary guidelines, protocols and interprofessional education to support an integrated rehabilitation service model in LMICs.

"I don't care about my mental health because I have a physical disability": A qualitative study on the mental healthcare-seeking behaviours of people with disabilities in Bangladesh

In Bangladesh, people living with disabilities are one of the most vulnerable groups, as they receive little or no assistance. They face numerous challenges regarding financial, social, and access to basic education and healthcare, which contribute to experiences of distress and mental health issues. However, there is limited research on the mental health needs of people with disabilities and the accessibility of mental health services in Bangladesh. This qualitative study addresses this gap by examining the mental healthcare-seeking behaviours of people with disabilities and challenges in care-seeking pathways and recommendations for devising an inclusive system in existing mental health services through key informant interviews and focus group discussions with 55 participants from four stakeholder groups. Findings highlight that limited mental health, literacy, stigma, and financial and logistical challenges, such as inaccessible transportation and distant facilities, hinder access to care. System-level barriers, including a lack of specialists and inadequate community-based services, further exacerbate the issue. Stakeholders recommended strengthening social support systems by providing disability identity cards, allowances, and access to inclusive education and employment opportunities. They also emphasized the need for awareness campaigns, better transportation options, and training for healthcare workers. Policymakers are urged to design culturally relevant needs-based interventions to improve mental healthcare pathways for people with disabilities while promoting multisectoral collaboration.

Users' satisfaction and experiences in using assistive devices distributed by a rehabilitation centre in Bangladesh: a cross-sectional study

PURPOSE

This study aimed to understand Bangladeshi users' satisfaction with their assistive devices, including (a) device characteristics, e.g., size, weight, safety, ease of use, comfort, and effectiveness, and (b) availability of parts and repair services. We also described how frequently individuals with disabilities living in the community used assistive devices in their daily activities and how the use of assistive devices promoted individuals' wellbeing.

METHOD

We conducted a cross-sectional survey with assistive device users or their guardians (if under 18) in Bangladesh about their experience and satisfaction with their assistive device 6 months after receiving it. The research team developed a survey questionnaire consisting of both closed and open-ended questions. All data were collected via telephone interviews. We employed descriptive statistics to analyse quantitative data and inductive analysis for the qualitative data.

RESULTS

We found that out of the 376 participants, nearly 95% used assistive devices on a regular basis, and their satisfaction with the devices was high. Participants reported that assistive devices improved mobility, independence, and wellbeing of persons with disabilities. A few participants (6.4%) reported that their devices were damaged. Some participants identified concerns with their assistive devices, including (i) inappropriate size of ankle-foot orthoses, manual self-propelled wheelchairs, and prostheses, (ii) back slabs (a type of brace) being too short, and (iii) walking frames being too large. Several participants noted pain and discomfort when they used their assistive device. Additionally, some participants stated that environmental factors (e.g., muddy roads) contributed to the disrepair of their assistive devices. Finally, participants recounted that repair services were limited in rural areas of Bangladesh.

CONCLUSION

These findings indicate that the provision of assistive devices requires accommodating individuals' needs and ensuring appropriate environments in which to function. The results support the need for follow-up services after distributing assistive devices. Further research could explore the impact of assistive devices on the family quality of life of persons with disabilities.IMPLICATIONS FOR REHABILITATIONIt is essential for rehabilitation professionals to conduct follow-up services after distributing assistive devices among persons with disabilities.There is a need for the government of Bangladesh to revisit the Rights and Protection of Persons with Disability Act of 2013 and provide further clarity about their commitment to the provision of assistive devices and associated services (e.g., repair services) and its subsequent implementation.Policymakers in Bangladesh must be proactive to translate policy commitments into practice, as it relates to building an accessible environment for people using assistive devices. Further, government efforts are needed to educate policy implementers in all relevant ministries so that all responsible bodies are fully familiar with their national and international commitments regarding the rights of persons with disabilities.Future research could (i) include user's satisfaction with the service delivery process and (ii) measure the impact of assistive devices on family quality of life of persons with disabilities.

Needs and readiness to use tele-practice for identification and rehabilitation of children with hearing and speech-language disorders: perceptions of public sector care providers in South India

The current study was a first step towards planning the implementation of tele-practice in a South Indian state's public-sector services for childhood hearing and speech, language disorders. The aim was to understand the perceptions of public-sector health care providers (HCPs) regarding their need and readiness to accept and implement tele-practice-based diagnostics and rehabilitation services. A cross-sectional study design was used, which included focus group discussions (FGDs), semi-structured interviews (SSIs) and geo-spatial analysis. Participants in the qualitative component included various cadres of health HCPs in public-sector services. Theoretical saturation and cross-case variance were used to assess the data's sufficiency. A hybrid deductive-inductive thematic analytical approach was used to analyse the data. Geo-tags and geo-locations of addresses of all children with disabilities and all the public-sector service providers were used to generate geospatial maps. The HCPs considered the currently available services for childhood hearing and speech-language disorders to be insufficient and reported shortage of professionals to meet current demands. There was inconsistent availability of suitable equipment and professionals in the existing district-level facilities. HCPs were comfortable using technology, and were willing to investigate tele-practice, but they required training in tele-practice [Q2].

Stroke systems of care in South-East Asia Region (SEAR): commonalities and diversities

The Southeast Asia Region (SEAR) accounts for nearly 50% of the developing world's stroke burden. With various commonalities across its countries concerning health services, user awareness, and healthcare-seeking behavior, SEAR still presents profound diversities in stroke-related services across the continuum of care. This review highlights the numerous systems and challenges in access to stroke care, acute stroke care services, and health care systems, including rehabilitation. The paper has also attempted to compile information on the availability of stroke specialized centers, Intravenous thrombolysis (IVT) ready centers, Endovascular therapy (EVT) ready centers, rehabilitation centers, and workforce against a backdrop of each country's population. Lastly, the efforts of WHO (SEARO)-CMCL (World Health Organization-South East Asia region, Christian Medical College & Hospital Ludhiana) collaboration towards improving stroke services and capacity among the SEAR have been described.

Situation analysis model of hospital emergency department promotion in Iran: A cross-sectional study

Background and Aim

The present study was conducted to develop a situation analysis model for Iran's hospitals' emergency departments (EDs).

Methods

The current research was a descriptive cross-sectional applied study in three stages. The studies were reviewed in various library resources and valid sites in the first stage. In the second stage, the analysis model of the ED in Iran was presented. In the third stage, the model was validated based on the Delphi technique, and the final model was presented.

Results

The final situation analysis model of ED in Iran was approved in four main aspects, including goals, internal factors, external factors, and organizations and institutions participating in the situation analysis, and its implementation schedule was approved by 90% of experts.

Conclusion

Considering the importance of situation analysis in developing a strategic plan and improving the quality of health services in the ED of hospitals, implementing a coherent situation analysis model that includes all aspects leading to improving the ED quality and analyzing the internal and external factors is vital.

A situational analysis of ear and hearing care in South Korea using WHO ear and Hearing Care Situation Analysis tool

Objectives

The WHO emphasizes lifelong management of hearing diseases such as hearing loss and advocates for prevention. The Ear and Hearing Care Situation Analysis (EHCSA) tool was designed by the WHO for assessment and quality improvement of state-led management of hearing loss prevention and management programs. The purpose of this study was to use the EHCSA to assess the ear and hearing management program in Korea and to establish goals consistent with best practices for improving policies and services related to ear and hearing care.

Methods

The EHCSA was used as a need assessment of the ear and hearing management services in the country. The EHCSA consists of two sections. Section 1 consists of 41 questions to evaluate health policies and support services. Section 2 consists of 203 questions to evaluate human resources and services of the ear and hearing management sector.

Results

There are an estimated 800,000 people with hearing loss in Korea. Policies such as hearing aid support are in place, and outreach services such as free hearing tests are also being actively conducted. In all medical institutions, ear and hearing management treatment and medication prescriptions could be received without barriers. Workers in the fields of ear and hearing management, such as audiologists, language therapists, special education teachers, and sign language interpreters, are specialized and have well-established guidelines for training.

Conclusion

Overall, the domestic ear and hearing management sector has confirmed that policies and services are well-prepared in comparison with advanced countries such as the United States, Iran, and China. The use of the EHCSA was functional in collecting data on the current state of domestic ear and hearing management policies and services in Korea, can be used for continuous quality improvement and expansion of medical services, and can be used as a reporting mechanism to the WHO.

Examining the impact of spatial accessibility to rehabilitation facilities on the degree of disability: A heterogeneity perspective

The positive effect of healthcare facilities on residents' health has been extensively studied. However, few studies have focused on the role of rehabilitation services as unique healthcare services for persons with disabilities. This study aimed to examine the relationship between the spatial accessibility of rehabilitation facilities and the degree of disability. To this end, an approach of measuring the spatial accessibility of rehabilitation facilities to persons with disabilities was proposed. This approach integrates multiple key elements including the characteristics of facilities (i.e., the capacity, frequency of use and service radius), characteristics of the mobility of persons with disabilities (i.e., the mode of travel, escort support, transportation fee and barrier-free environment requirements) and travel time obtained from a routing application programme interface. The accessibility of rehabilitation facilities was calculated at the neighbourhood level within the Central Urban Area of Tianjin Municipality. The ordinal logistic regression analysis revealed that higher accessibility to rehabilitation facilities generally corresponded to lower severity of disability. However, the impact varied depending on the type of disability. Increased accessibility was associated with greater severity of intellectual disability, whereas it was linked to reduced severity of visual, hearing, limb, mental and speech disabilities. It is suggested to incorporate disability diversity and the accessibility of rehabilitation facilities into spatial planning and governance.

Prosthesis use among individuals with lower limb amputation in Bangladesh

OBJECTIVE

This study aimed to assess factors related to prostheses use among individuals with lower limb amputation in Bangladesh.

METHODS

Data related to prosthesis use, functional capabilities (as measured with the Locomotor Capabilities Index [LCI]), and user satisfaction were collected using telephone interviews between January 2014 and October 2016. Descriptive and regression analyses were performed.

RESULTS

This study involved 183 participants (89.6% male); the mean (SD) age was 49.5 (10.7) years. Most of the participants (95.6%) used prostheses daily, and the mean (SD) duration of use was 7.0 (4.1) hours per day. The mean (SD) basic LCI score, advanced LCI score, and total LCI score were 25.1 (4.9), 20.8 (8.3), and 45.9 (12.2), respectively. Among them, 36.7% were dissatisfied with the weight of the prosthesis. Having a below knee amputation (odds ratio 2.6 and confidence interval 1.3, 5.3) and absence of comorbidities (odds ratio 2.1; confidence interval 1.0, 4.4) were associated significantly with an increased use of prosthesis.

CONCLUSION

Factors such as weight of the prosthesis, amputation level, and presence of comorbidities are important considerations while planning for prosthetic rehabilitation and optimize utilization of the prosthetic devices.

Relations between indoor rehabilitation and basic health services in a developing country

Background

and Introduction: Physical rehabilitation is vital for patients to regain maximum function. Approximately 80% of people with a disability live in developing countries, where they face multiple challenges in rehabilitation. The goal of the study was to conduct an analysis of indoor rehabilitation programs based on the demographics and medical conditions of the admitted patients and to relate to the available basic health and rehabilitation facilities.

Methods

This was a mixed method study conducted in an inpatient rehabilitation ward of a tertiary level academic university hospital in a developing country. All admitted patients who stayed for a period of minimum two weeks were included in the study. Demographic and clinical data were obtained by means of a retrospective medical record review utilizing a standardized data extraction form. The study was further strengthened by an online literature search for the available documents for analysis, relation, and discussion.

Results

Among the 1,309 admitted patients was male- female ratio was 10:7, with the majority (31.4%) cases falling between the ages of 46 and 60yrs. Rehabilitation outpatient department was the principal mode of admission (78%), and musculoskeletal and neurological conditions represented the maximum number (79.8%). Majority of patients (60.8%) were discharged home on completion of the rehabilitation program with a large number of patients who were absconded. Poor health budget allocation and lack of prioritization of the rehabilitation sector face multiple challenges, including the rehabilitation team functioning resources, space crisis for expansion which was further impacted by the COVID-19 pandemic.

Conclusions

The country's current health-related rehabilitation process and socio-demographic variables have a negative relationship. There was a large number of missing data in the medical records and many patients were lost prematurely from the indoor rehabilitation program. Musculoskeletal disorders were common, and the majority of patients were discharged home once the program was completed.

SUpporting People in extreme POverty with Rehabilitation and Therapy (SUPPORT CP): a trial among families of children with cerebral palsy in Bangladesh

AIM

To test the efficacy of an integrated microfinance/livelihood and community-based rehabilitation (IMCBR) programme in improving health-related quality of life (HRQoL) and motor function of children with cerebral palsy (CP) and gain in social capital to their ultra-poor families in rural Bangladesh.

METHOD

This was an open-label cluster randomized control trial. Children with CP aged 5 years or under were randomly allocated to three arms; Arm A: IMCBR; Arm B: community-based rehabilitation (CBR); and Arm C: care-as-usual. The CBR was modified with phone follow-up followed by home-based CBR at 2.5 months post-enrolment because of the COVID-19 pandemic. Intention-to-treat analysis was performed.

RESULTS

Twenty-four clusters constituting 251 children-primary caregivers' dyads were assigned to three arms (Arm A = 80; Arm B = 82; Arm C = 89). Between baseline and endline, the percentage mean change in the physical functioning domain of HRQoL was highest in Arm A (30.0%) with a significant mean difference between Arm A and Arm B (p = 0.015). Improvement in the mean social capital score was significantly higher in Arm A compared to Arm C (p < 0.001).

INTERPRETATION

The findings suggest that IMCBR could improve the HRQoL of children with CP and the social capital of their ultra-poor families. Long-term follow-up of the trial participants and future exploration of such interventions are essential. The integrated livelihood and CBR programme holds potential to improve health and well-being of children with CP and their ultra-poor families.

Successful Use of a 5G-Based Robot-Assisted Remote Ultrasound System in a Care Center for Disabled Patients in Rural China

Background

Disability has become a global population health challenge. Due to difficulties in self-care or independent living, patients with disability mainly live in community-based care centers or institutions for long-term care. Nonetheless, these settings often lack basic medical resources, such as ultrasonography. Thus, remote ultrasonic robot technology for clinical applications across wide regions is imperative. To date, few experiences of remote diagnostic systems in rural care centers have been reported.

Objective

To assess the feasibility of a fifth-generation cellular technology (5G)-based robot-assisted remote ultrasound system in a care center for disabled patients in rural China.

Methods

Patients underwent remote robot-assisted and bedside ultrasound examinations of the liver, gallbladder, spleen, and kidneys. We compared the diagnostic consistency and differences between the two modalities and evaluated the examination duration, image quality, and safety.

Results

Forty-nine patients were included (21 men; mean age: 61.0 ± 19.0 [range: 19-91] years). Thirty-nine and ten had positive and negative results, respectively; 67 lesions were detected. Comparing the methods, 41 and 8 patients had consistent and inconsistent diagnoses, respectively. The McNemar and kappa values were 0.727 and 0.601, respectively. The mean duration of remote and bedside examinations was 12.2 ± 4.5 (range: 5-26) min and 7.5 ± 1.8 (range: 5-13) min (p < 0.001), respectively. The median image score for original images on the patient side and transmitted images on the doctor side was 5 points (interquartile range: [IQR]: 4.7-5.0) and 4.7 points (IQR: 4.5-5.0) (p = 0.176), respectively. No obvious complications from the examination were reported.

Conclusions

A 5G-based robot-assisted remote ultrasound system is feasible and has comparable diagnostic efficiency to traditional bedside ultrasound. This system may provide a unique solution for basic ultrasound diagnostic services in primary healthcare settings.

Nutrition Interventions for Children with Cerebral Palsy in Low- and Middle-Income Countries: A Scoping Review

BACKGROUND

Malnutrition is substantially higher among children with cerebral palsy (CP) in low- and middle-income countries (LMICs) when compared with the general population. Access to appropriate interventions is crucial for better management of malnutrition and nutritional outcomes of those children. We aimed to review the existing evidence on nutrition interventions for children with CP in LMICs.

METHODS

Online databases, i.e., PubMed and Scopus, and Google Scholar were searched up to 10 January 2022, to identify peer-reviewed publications/evidence on LMIC focused nutritional management guidelines/interventions. Following title screening and abstract review, full articles that met the inclusion/exclusion criteria were retained for data charting. Information about the study characteristics, nutrition interventions, and their effectiveness were extracted. Descriptive data were reported.

RESULTS

Eight articles published between 2008 and 2019 were included with data from a total of n = 252 children with CP (age range: 1 y 0 m-18 y 7 m, 42% female). Five studies followed experimental design; n = 6 were conducted in hospital/clinic/center-based settings. Four studies focused on parental/caregiver training; n = 2 studies had surgical interventions (i.e., gastrostomy) and n = 1 provided neurodevelopmental therapy feeding intervention. Dietary modification as an intervention (or component) was reported in n = 5 studies and had better effect on the nutritional outcomes of children with CP compared to interventions focused on feeding skills or other behavioral modifications. Surgical interventions improved nutritional outcomes in both studies; however, none documented any adverse consequences of the surgical interventions.

CONCLUSION

There is a substantial knowledge gap on nutrition interventions for children with CP in LMICs. This hinders the development of best practice guidelines for the nutritional management of children with CP in those settings. Findings suggest interventions directly related to growth/feeding of children had a better outcome than behavioral interventions. This should be considered in planning of nutrition-focused intervention or comprehensive services for children with CP in LMICs.

A Social Business Model of Early Intervention and Rehabilitation for People with Disability in Rural Bangladesh

Background: Despite the high burden of childhood disability in low-and middle-income countries (LMICs), the opportunity for early intervention and rehabilitation is very limited. Studies have found that community-based rehabilitation service is effective for children with cerebral palsy (CP); however, such services are not readily available in LMICs, and services run by non-profit organisations on external funding are often not sustainable. In this study, we report the lesson learnt in establishing a social business model of early intervention and rehabilitation services for children with CP and adults with disabilities in a rural subdistrict of Bangladesh. Methods: Case study of a rural early intervention and rehabilitation centre (i.e., the model centre) implemented between May 2018 and September 2019. An economic evaluation incorporating gross margin analysis along with descriptive statistics was performed to assess the social business potentials of the model centre. Results: The establishment of this model centre cost ~5955 USD with an average monthly running cost of ~994 USD. During the 17 months study period, 7038 therapy sessions (average eight sessions per patient) were offered to 862 patients with musculoskeletal and neurological disorders. The most common clinical presentations were low back pain (35.6%; n = 307). Six percent (n = 52) of the attendees were children with CP (mean (SD) age 6.3 (4.0) years; 35.7% (n = 19) were female), who received 1392 sessions, on average 27 sessions per child. The centre reached the break-even point at the 13th month and remained profitable for the next 4 months of the study period. An average session fee of 2.2 USD resulted in a gross margin of -1458 USD and 1940 USD in 2018 and 2019, respectively. Revenue to cost ratios for the 2 years were 0.27:1 and 0.51:1 while average rates of return were −41.4% and 10.1%, respectively. Sensitivity analysis revealed that session numbers including 5000, 6000, 7000, 8000, 9000, and 10,000 were required to break even at the session fees of 3.0, 2.50, 2.0, 2.0, 1.5, and 1.5 USD, respectively. Conclusion: Our social business model of an early intervention and rehabilitation service provides evidence of enhancing access to services for children with CP as well as adults with disabilities while ensuring the sustainability of the services in rural Bangladesh.

Supporting Ultra Poor People with Rehabilitation and Therapy among families of children with Cerebral Palsy in rural Bangladesh (SUPPORT CP): Protocol of a randomised controlled trial

INTRODUCTION

Poverty is a key contributor to delayed diagnosis and limited access to early intervention and rehabilitation for children with cerebral palsy (CP) in rural Bangladesh. 97% of families of children with CP live below the poverty line in Bangladesh. Therefore, in low-and middle-income countries (LMICs), efforts to improve outcomes for children with CP (including health-related quality of life, motor function, communication, and nutritional attainments) should also include measures to improve family economic and social capital. We propose a randomised controlled trial (RCT) to evaluate the effectiveness of an integrated microfinance/livelihood and community-based rehabilitation (IMCBR) program for ultra-poor families of children with CP in rural Bangladesh.

MATERIAL AND METHODS

This will be a cluster RCT comparing three arms: (a) integrated microfinance/livelihood and community-based rehabilitation (IMCBR); (b) community-based rehabilitation (CBR) alone; and (c) care-as-usual (i.e. no intervention). Seven clusters will be recruited within each arm. Each cluster will consist of 10 child-caregiver dyads totalling 21 clusters with 210 dyads. Parents recruited in the IMCBR arm will take part in a microfinance/livelihood program and Parent Training Module (PTM), their children with CP will take part in a Goal Directed Training (GDT) program. The programs will be facilitated by specially trained Community Rehabilitation Officers. The CBR arm includes the same PTM and GDT interventions excluding the microfinance/livelihood program. The care-as-usual arm will be provided with information about early intervention and rehabilitation. The assessors will be blinded to group allocation. The duration of the intervention will be 12 months; outcomes will be measured at baseline, 6 months, 12 months, and 18 months.

CONCLUSION

This will be the first RCT of an integrated microfinance/livelihood and CBR program for children with CP in LMIC settings. Evidence from the study could transform approaches to improving wellbeing of children with CP and their ultra-poor families.

Epidemiology of Malnutrition among Children with Cerebral Palsy in Low- and Middle-Income Countries: Findings from the Global LMIC CP Register

Background: This study aimed to describe the epidemiology of malnutrition among children with cerebral palsy (CP) in low- and middle-income countries (LMICs). Methods: Data from children with confirmed CP aged <18 years registered into the Global LMIC CP Register (GLM CPR) from Bangladesh, Indonesia, Nepal, and Ghana were included. Anthropometric measurements were collected, and nutritional status was determined following the WHO guidelines. Descriptive statistics and adjusted logistic regression were used to describe the nutritional status and identify predictors of malnutrition. Results: Between January 2015 and December 2020, 3619 children with CP were registered into the GLM CPR (median age at assessment: 7.0 years, 39% female). Overall, 72–98% of children from Bangladesh, Indonesia, Nepal, and Ghana had at least one form of undernutrition. The adjusted analysis showed, older age, low maternal education, spastic tri/quadriplegia, and Gross Motor Functional Classification System (GMFCS) levels III–V were significant predictors of underweight and stunting among children with CP in Bangladesh. In Nepal, female children, GMFCS III–V had higher odds of underweight and stunting. In Ghana, low maternal education was significantly associated with underweight, whereas older age and the presence of associated impairments were the significant predictors of stunting among children with CP. Having a GMFCS of III–V increased the odds of being underweight among children in Indonesia; however, no predictors were identified for stunting, as nearly all children with CP registered from Indonesia were stunted. Conclusion: Most children with CP in GLM CPR had undernutrition. Maternal education and moderate-to-severe motor impairment (GMFCS III–V) were significant predictors. Practical nutrition education to mothers/caregivers and management guidelines according to the motor severity using local resources could improve the nutritional outcome of children with CP in LMICs.

Outcome of Community-Based Early Intervention and Rehabilitation for Children with Cerebral Palsy in Rural Bangladesh: A Quasi-Experimental Study

We evaluated the outcome of a community-based early intervention and habilitation for children with cerebral palsy (CP) in Bangladesh. Children registered on the Bangladesh CP Register (BCPR) were recruited in two groups for this study: Group A received a comprehensive six-month long community-based caregiver-led intervention program at the “Shishu Shorgo” (Bengali title, which translates to ‘Children’s Heaven’) Early Intervention and Rehabilitation Centres developed to support participants from the BCPR. Group B received standard care. A quasi-experimental study was conducted. Data were obtained at baseline, at the end of the program (i.e., 6 months), and at a 12-month follow-up. Outcome measures for children included gross motor functional measure (GMFM-66), Communication Function Classification System (CFCS), and Viking Speech Scale (VSS) and, for adult caregivers, the depression, anxiety, and stress scale (DASS 21). Between October 2016 and March 2017, 156 children with CP were recruited (77 in Group A and 79 in Group B). The total score of GMFM-66, CFCS level, and VSS level significantly improved statistically in Group A (p < 0.05 for all) and deteriorated in Group B (p < 0.001, p = 0.095, p = 0.232). The intervention showed promising outcomes particularly for children with CP under five years of age. There is a need for caregiver-led community-based programs for children with CP in LMICs.

Predictors of Rehabilitation Service Utilisation among Children with Cerebral Palsy (CP) in Low- and Middle-Income Countries (LMIC): Findings from the Global LMIC CP Register

BACKGROUND

We assessed the rehabilitation status and predictors of rehabilitation service utilisation among children with cerebral palsy (CP) in selected low- and middle-income countries (LMICs).

METHODS

Data from the Global LMIC CP Register (GLM-CPR), a multi-country register of children with CP aged <18 years in selected countries, were used. Descriptive and inferential statistics (e.g., adjusted odds ratios) were reported.

RESULTS

Between January 2015 and December 2019, 3441 children were registered from Bangladesh (n = 2852), Indonesia (n = 130), Nepal (n = 182), and Ghana (n = 277). The proportion of children who never received rehabilitation was 49.8% (n = 1411) in Bangladesh, 45.8% (n = 82) in Nepal, 66.2% (n = 86) in Indonesia, and 26.7% (n = 74) in Ghana. The mean (Standard Deviation) age of commencing rehabilitation services was relatively delayed in Nepal (3.9 (3.1) year). Lack of awareness was the most frequently reported reason for not receiving rehabilitation in all four countries. Common predictors of not receiving rehabilitation were older age at assessment (i.e., age of children at the time of the data collection), low parental education and family income, mild functional limitation, and associated impairments (i.e., hearing and/or intellectual impairments). Additionally, gender of the children significantly influenced rehabilitation service utilisation in Bangladesh.

CONCLUSIONS

Child's age, functional limitation and associated impairments, and parental education and economic status influenced the rehabilitation utilisation among children with CP in LMICs. Policymakers and service providers could use these findings to increase access to rehabilitation and improve equity in rehabilitation service utilisation for better functional outcome of children with CP.