Development of mental health and psychosocial support (MHPSS) guidelines for deaf and hard of hearing children in the Gaza Strip

Deaf and hard of hearing children in the Gaza Strip may be at risk of mental health conditions and psychological distress, as a result of social exclusion and limited accessible communication. This article presents the process and research methods used to develop guidelines for schools in the Gaza Strip on mental health and psychosocial support for deaf and hard of hearing children. The process was guided by the GIN-McMaster guideline development checklist across four steps: (1) priority settings; (2) searching for evidence; (3) developing recommendations; (4) evaluation. Priority setting was spearheaded by local and international researchers, and a local steering committee comprised of deaf and hard of hearing representatives, school administration and staff, mental health specialists, family members and government officials. In searching for evidence, and in order to generate evidence-based recommendations for the guidelines, we utilised a scoping review of global mental health support for deaf and hard of hearing children and qualitative research with deaf and hard of hearing children and adults, families and teachers. Two pilot studies were conducted in mainstream and specialist educational settings as way of evaluation. The scoping review and qualitative research identified various content for the guidelines, including the importance of information on disability and deafness, promoting social inclusion and self-esteem, and accessible learning environments. The pilot studies demonstrated feasibility and acceptability among teachers and deaf and hard of hearing children, although teachers need sufficient support and resources to implement. Now finalised, the guidelines are being distributed to schools in the Gaza Strip to support the mental health and wellbeing of deaf and hard of hearing children.

Communication, inclusion and psychological wellbeing among deaf and hard of hearing children: A qualitative study in the Gaza Strip

Deaf and hard of hearing children are at risk of exclusion from community life and education, which may increase their risk of mental health conditions. This study explores the experience of deaf and hard of hearing children in the Gaza Strip, with particular focus on the factors that contribute to psychological wellbeing and distress. In-depth interviews were conducted with 17 deaf and hard of hearing children, 10 caregivers of deaf and hard of hearing children and eight teachers of deaf and hard of hearing children in mainstream and special schools, across the Gaza Strip. Further, three focus group discussions were held with deaf and hard of hearing adults and disability leaders, mental health specialists and other teachers of deaf and hard of hearing children. Data collection was completed in August 2020. Key themes identified in the analysis included lack of accessible communication, community exclusion, negative attitudes towards hearing impairment and deafness and the impact on deaf and hard of hearing children's sense of self, and limited family knowledge on hearing impairment and deafness. Further findings focused on strategies to improve the inclusion of deaf and hard of hearing children and how to promote wellbeing. In conclusion, participants in this study believed that deaf and hard of hearing children in the Gaza Strip are at increased risk of mental health conditions. Changes are needed across community and government structures, including education systems, to promote the inclusion of deaf and hard of hearing children and to support their psychological wellbeing. Recommendations from the findings include increasing efforts to improve awareness and reduce stigma, providing better access to sign language for deaf and hard of hearing children, and offering training for teachers of deaf and hard of hearing children, especially in mainstream environments.

Prevalence of Cognitive Impairment and Its Association With Hearing Loss Among Adults Over 50 Years of Age: Results From a Population-Based Survey in Santiago, Chile

PURPOSE

The purpose of this study was to estimate the prevalence of cognitive impairment and explore its association with hearing loss and other sociodemographic and clinical risk factors, using an objective measurement of hearing levels, in adults over 50 years of age.

METHOD

A population-based survey was completed in Santiago, Chile between December 2019 and March 2020. Participants were screened for cognitive impairment using the Short Chilean Mini-Mental State Examination and hearing levels were assessed with tonal audiometry (hearTest). Data on demographic, socioeconomic, and clinical characteristics were collected.

RESULTS

A total of 538 persons completed the assessment. The prevalence of cognitive impairment in the 50+ population was 9.3% (95% confidence interval [CI] [5.8, 14.7]). Cognitive impairment was significantly higher in individuals with any level of hearing loss (odds ratio [OR] = 2.19, 95% CI [1.00, 4.80], adjusted for age, sex, education, socioeconomic position [SEP], and head trauma). Subjects with hearing loss and who reported any use of hearing aids (16% of the sample) had a lower risk of cognitive impairment (OR of nonusers 3.64, 95% CI [1.00, 13.28], adjusted for age, sex, education, SEP, and head trauma).

CONCLUSION

Strategies for addressing cognitive impairment should further explore the integration of early diagnosis of hearing loss and the regular use of hearing aids.

Prevalence, risk factors and causes of hearing loss among adults 50 years and older in Santiago, Chile: results from a rapid assessment of hearing loss survey

OBJECTIVE

Among a representative sample of adults aged 50 years and older too (i) determine the prevalence of hearing loss, (ii) evaluate probable causes and risk factors of hearing loss, and (iii) assess the association between hearing loss measured by audiometry and self-report.

DESIGN

A population-based survey of adults aged 50 and older in Santiago, Chile using the Rapid Assessment of Hearing Loss (RAHL) survey.

STUDY SAMPLE

538 participants completed a questionnaire, which included questions on socio-demographic and health characteristics and self-reported hearing loss. Hearing and possible cause of hearing loss was assessed using pure tone audiometry (0.5-4.0 kHz), tympanometry, and otoscopy.

RESULTS

The prevalence of any level of hearing loss in adults aged 50 years and older was 41% (95% CI 33.2, 49.2). In terms of aetiologies, 89.3% of ears with mild or worse hearing loss were classified as sensorineural. Otoscopy was abnormal in 10.7% of subjects with impacted earwax being the most common finding (4.4%) followed by chronic otitis media (3.5%). Hearing aid usage was 16.6%. Older age, lower socioeconomic position, lack of education, and solvent exposure were significantly associated with hearing loss.

CONCLUSION

Hearing loss among individuals aged over 50 years was common in Santiago, Chile.

Disability and the achievement of Universal Health Coverage in the Maldives

OBJECTIVE

To assess access to general and disability-related health care among people with disabilities in the Maldives.

METHODS

This study uses data from a case-control study (n = 711) nested within a population-based, nationally representative survey to compare health status and access to general healthcare amongst people with and without disabilities. Cases and controls were matched by gender, location and age. Unmet need for disability-related healthcare is also assessed. Multivariate regression was used for comparisons between people with and without disabilities.

RESULTS

People with disabilities had poorer levels of health compared to people without disabilities, including poorer self-rated health, increased likelihood of having a chronic condition and of having had a serious health event in the previous 12 months. Although most people with and without disabilities sought care when needed, people with disabilities were much more likely to report difficulties when routinely accessing healthcare services compared to people without disabilities. Additionally, 24% of people with disabilities reported an unmet need for disability-related healthcare, which was highest amongst people with hearing, communication and cognitive difficulties, as well as amongst older adults and people living in the lowest income per capita quartile. Median healthcare spending in the past month was modest for people with and without disabilities. However, people with disabilities appear to have high episodic healthcare costs, such as for disability-related healthcare and when experiencing a serious health event.

CONCLUSIONS

This study found evidence that people with disabilities experience unmet needs for both disability-related and general healthcare. There is therefore evidence that people with disabilities in the Maldives are falling behind in core components relevant to UHC: availability of all services needed, and quality and affordability of healthcare.

Anxiety and depression in Guatemala: Sociodemographic characteristics and service access

Epidemiological data on depression and anxiety in Guatemala is lacking. Using 2016 National Disability Survey data, we explored the sociodemographics of people with anxiety and/or depression and its heightened burden on access to key services. The survey (n = 13,073) used the Washington Group Extended Set to estimate disability prevalence, including anxiety and/or depression. A nested case-control study was included to explore the impact of disability on key life areas. Cases (indicating ‘A lot of difficulty’ or ‘Cannot do’ in one or more functional domain) and age-/sex-matched controls were administered a structured questionnaire. Multivariable logistic regression and heightened-burden analysis were conducted. Higher odds of anxiety and/or depression were found in participants who were 50+ (aOR 2.3, 1.8–3.1), female (aOR 1.8, 1.4–2.2), urban (aOR 1.5, 1.2–1.9), divorced/separated (aOR 2.0, 1.3–3.0), and widowed (aOR 1.6, 1.0–2.4), as well as those with impaired communication or cognition (aOR 17.6, 13.0–23.8), self-care (aOR 13.2, 8.5–20.5), walking (aOR 13.3, 9.7–18.3), hearing (aOR 8.5, 5.6–13.1), and vision (aOR 8.5, 6.1–11.8). Lower odds of anxiety and/or depression were found in participants with a university education (aOR 0.2, 0.5–0.9), and those living in the southeast (aOR 0.2, 0.1–0.3) or northeast (aOR 0.3, 0.2–0.4). Compared to people with impairments that were not depression and/or anxiety, people with depression and/or anxiety were less likely to receive a retirement pension (aOR 0.4, 0.2–0.8), and more likely to receive medication for depression/anxiety (aOR 4.1, 1.9–9.1), report a serious health problem (aOR 1.8, 1.3–2.5), and seek advice/treatment with a government health worker/health post (aOR 6.3, 1.0–39.2).

Estimating need and coverage for five priority assistive products: a systematic review of global population-based research

INTRODUCTION

To improve access to assistive products (APs) globally, data must be available to inform evidence-based decision-making, policy development and evaluation, and market-shaping interventions.

METHODS

This systematic review was undertaken to identify studies presenting population-based estimates of need and coverage for five APs (hearing aids, limb prostheses, wheelchairs, glasses and personal digital assistants) grouped by four functional domains (hearing, mobility, vision and cognition).

RESULTS

Data including 656 AP access indicators were extracted from 207 studies, most of which (n=199, 96%) were cross-sectional, either collecting primary (n=167) or using secondary (n=32) data. There was considerable heterogeneity in assessment approaches used and how AP indicators were reported; over half (n=110) used a combination of clinical and self-reported assessment data. Of 35 studies reporting AP use out of all people with functional difficulty in the corresponding functional domains, the proportions ranged from 4.5% to 47.0% for hearing aids, from 0.9% to 17.6% for mobility devices, and from 0.1% to 86.6% for near and distance glasses. Studies reporting AP need indicators demonstrated >60% unmet need for each of the five APs in most settings.

CONCLUSION

Variation in definitions of indicators of AP access have likely led to overestimates/underestimates of need and coverage, particularly, where the relationship between functioning difficulty and the need for an AP is complex. This review demonstrates high unmet need for APs globally, due in part to disparate data across this sector, and emphasises the need to standardise AP data collection and reporting strategies to provide a comparable evidence base to improve access to APs.

Childhood musculoskeletal impairment in Malawi from traumatic and non-traumatic causes: a population- based assessment using the key informant method

Background

Musculoskeletal impairment (MSI) in children is an under-recognised public health challenge. Although preventable, road injuries and other traumas continue to cause significant impairments to children worldwide. The study aimed to use the Key Informant Method (KIM) to assess prevalence and causes of MSI in children in two districts in Malawi, estimating the associated need for services provision, with a focus on traumatic aetiology.

Methods

The KIM was conducted in the districts of Thyolo (Southern Malawi) and Ntcheu (Central Malawi) in 2013. Five hundred key informants were trained to identify children who may have one of a range of MSI. The identified children were referred to a screening camp where they were examined by medical experts with standardised assessment protocols for diagnosing each form of impairment.

Results

15,000 children were referred to screening camps. 7220 children were assessed (response rate 48%) for an impairment of whom 15.2% (1094) had an MSI. 13% of children developed MSI from trauma, while 54% had a neurological aetiology. For MSI of traumatic origin the most common body part affected was the elbow. Less than half of children with MSI (44.4%) were enrolled in school and none of these children attended schools with resources for disability. More than half of children with MSI (60%) had not received required services and 64% required further physical therapy.

Conclusions

The KIM method was used to identify a high prevalence of MSI among children in two districts of Malawi and estimates an unmet need for dedicated MSI services.

Measuring assistive technology supply and demand: A scoping review

The supply of and market demand for assistive products (APs) are complex and influenced by diverse stakeholders. The methods used to collect AP population-level market data are similarly varied. In this paper, we review current population-level AP supply and demand estimation methods for five priority APs and provide recommendations for improving national and global AP market evaluation.Abstracts resulting from a systematic search were double-screened. Extracted data include WHO world region, publication year, age-groups, AP domain(s), study method, and individual assessment approach.497 records were identified. Vision-related APs comprised 65% (n = 321 studies) of the body of literature; hearing (n = 59), mobility (n = 24), cognitive (n = 2), and studies measuring multiple domains (n = 92) were proportionately underrepresented. To assess individual AP need, 4 unique approaches were identified among 392 abstracts; 45% (n = 177) used self-report and 84% (n = 334) used clinical evaluation. Study methods were categorized among 431 abstracts; Cross-sectional studies (n = 312, 72%) and secondary analyses of cross-sectional data (n = 61, 14%) were most common. Case studies illustrating all methods are provided.Employing approaches and methods in the contexts where they are most well-suited to generate standardized AP indicators will be critical to further develop comparable population-level research informing supply and demand, ultimately expanding sustainable access to APs.

Disability among Syrian refugees living in Sultanbeyli, Istanbul: Results from a population-based survey

Objectives

To estimate the prevalence of disability among Syrian refugees living in Sultanbeyli district, Istanbul and compare people with and without disabilities in terms of demographic and socio-economic characteristics.

Methods

Using the municipality refugee database as the sampling frame, 80 clusters of 50 people (aged 2+ years) were selected using probability proportionate to size sampling of clusters and random selection of households within clusters. Disability assessment included: i) self-reported difficulties in functioning (using the Washington Group Short Set-Enhanced tool and Child Functioning Modules), ii) Rapid Assessment of Musculoskeletal Impairment and iii) screening for symptoms of common mental disorders for children aged 8–17.

Results

The overall prevalence of disability was 24.7% (95% CI 22.1–27.4), when including people self-reporting a lot of difficulty/cannot do in at least functional domain (15%, 95% CI 13.1–17.2), moderate/severe MSI (8.7%, 95% CI 7.6–9.9), and/or symptomatic anxiety, depression and PTSD among children 8–17 (21.0%, 95% CI 18.2–23.9). Men with disabilities were significantly less likely to be in paid work compared to their peers without disabilities (aOR 0.3 95% CI 0.2–0.5). Overall 60% of households included at least one person with a disability. Households with at least one person with a disability had a significantly higher dependency ratio, lower proportion of working-age adults in paid work, and were more likely to be female headed and in receipt of social protection schemes (p<0.05).

Conclusion

Disability is common among Syrian refugees in Sultanbeyli. People with disabilities in this setting experience greater vulnerability to poverty and exclusion from work, highlighting an urgent need for inclusive services, programmes and policies that are developed and implemented in partnership with people with disabilities.

Interrogating and Reflecting on Disability Prevalence Data Collected Using the Washington Group Tools: Results from Population-Based Surveys in Cameroon, Guatemala, India, Maldives, Nepal, Turkey and Vanuatu

The Washington Group (WG) tools capture self-reported functional limitations, ranging from 6 domains in the Short Set (SS) to 11 in the Extended Set (ESF). Prevalence estimates can vary considerably on account of differences between modules and the different applications of them. We compare prevalence estimates by WG module, threshold, application and domain to explore these nuances and consider whether alternative combinations of questions may be valuable in reduced sets. We conducted secondary analyses of seven population-based surveys (analyses restricted to adults 18+) in Low- and Middle-Income Countries that used the WG tools. The prevalence estimates using the SS standard threshold (a lot of difficulty or higher in one or more domain) varied between 3.2% (95% Confidence Interval 2.9-3.6) in Vanuatu to 14.1% (12.2-16.2) in Turkey. The prevalence was higher using the ESF than the SS, and much higher (5 to 10-fold) using a wider threshold of "some" or greater difficulty. Two of the SS domains (communication, self-care) identified few additional individuals with functional limitations. An alternative SS replacing these domains with the psychosocial domains of anxiety and depression would identify more participants with functional limitations for the same number of items. The WG tools are valuable for collecting harmonised population data on disability. It is important that the impact on prevalence of use of different modules, thresholds and applications is recognised. An alternative SS may capture a greater proportion of people with functional domains without increasing the number of items.

Disability among Older People: Analysis of Data from Disability Surveys in Six Low- and Middle-Income Countries

This analysis of surveys from six low- and middle-income countries (LMICs) aimed to (i) estimate the prevalence of disability among older adults and (ii) compare experiences and participation in key life areas among older people with and without disabilities which may show vulnerability during the COVID-19 pandemic. Data were analysed from district-level or national surveys in Cameroon, Guatemala, Haiti, India, Nepal and the Maldives, which across the six databases totalled 3499 participants aged 60 years and above including 691 people with disabilities. Disability was common among adults 60+, ranging from 9.7% (8.0–11.8) in Nepal to 39.2% in India (95% CI 34.1–44.5%). Mobility was the most commonly reported functional difficulty. In each setting, older people with disabilities were significantly less likely to be working and reported greater participation restrictions and environmental barriers in key life areas compared to people in the same age categories without disabilities (p < 0.05). Disability is common in this population, and older people with disabilities may have greater difficulties participating in COVID-19 responses and have high economic vulnerabilities. It is imperative to prioritise the needs of older people with disabilities in the COVID-19 pandemic, including ensuring accessibility of both health services and the community in general.

Estimating Need for Glasses and Hearing Aids in The Gambia: Results from a National Survey and Comparison of Clinical Impairment and Self-Report Assessment Approaches

Few estimates are available of the need for assistive devices (ADs) in African settings. This study aimed to estimate population-level need for glasses and hearing aids in The Gambia based on (1) clinical impairment assessment, and (2) self-reported AD awareness, and explore the relationship between the two methods. The Gambia 2019 National Eye Health Survey is a nationally representative population-based sample of 9188 adults aged 35+ years. Participants underwent standardised clinical vision assessments including the need for glasses (distance and near). Approximately 25% of the sample underwent clinical assessment of hearing and hearing aid need. Data were also collected on self-reported awareness, need and access barriers to vision and hearing ADs. Overall, 5.6% of the study population needed distance glasses (95% CI 5.0-6.3), 45.9% (95% CI 44.2-47.5) needed near glasses and 25.5% (95% CI 22.2-29.2) needed hearing aids. Coverage for each AD was very low (<4%). The agreement between self-report and clinical impairment assessment for AD need was poor. In conclusion, there is high prevalence and very low coverage for distance glasses, near glasses and hearing aids in The Gambia. Self-report measures alone will not provide an accurate estimate of AD need.

Shifting the focus to functioning: essential for achieving Sustainable Development Goal 3, inclusive Universal Health Coverage and supporting COVID-19 survivors

If Sustainable Developmental Goal 3 and Universal Health Coverage are to be achieved, functioning is a third health indicator which must be assessed and integrated into global health population-based metrics alongside mortality and morbidity. In this paper, we define functioning according to the International Classification of Functioning, Disability and Health (ICF) and present why functioning is important to measure, especially when considering the need for, and outcome of, rehabilitation and assistive technology. We discuss examples of tools that measure components of functioning through clinical assessment and self-report methodologies, and present the development of a comprehensive population level tool which aligns with the ICF and combines self-report and clinical measurement methods to measure functioning and the need for rehabilitation and AT. Throughout the paper a survivor of Coronavirus 2019 (COVID-19) is given as an example to illustrate functioning according to the ICF and how access to the interventions of rehabilitation and assistive technology might be of benefit to improve and optimise his/her functioning. We argue that the Global Health community must take action and ensure that the measurement of functioning is well established, accepted and integrated as the third health indicator following the COVID-19 pandemic.

Musculoskeletal impairment among Syrian refugees living in Sultanbeyli, Turkey: prevalence, cause, diagnosis and need for related services and assistive products

Background

Epidemiological data on musculoskeletal impairment (MSI) and related service and assistive product (AP) needs for displaced populations are lacking. This study aimed to estimate the prevalence, aetiology, and specific MSI diagnosis and the need for related services and APs among Syrian refugees living in Sultanbeyli, a district in Istanbul, Turkey.

Methods

A population-based survey used probability proportionate to size and compact segment sampling to select 80 clusters (‘street’) of 50 individuals (aged 2+), for total sample size of approximately 4000 participants. An updated version of the Rapid Assessment of MSI tool (RAM) was used to screen all participants using six questions. Any participant who screened positive underwent a standardised examination by a physiotherapist to assess the presence, aetiology, severity and specific diagnosis of MSI and an assessment of need for related services and APs.

Results

The all-age prevalence of MSI was 12.2% (95% CI 10.8–13.7) and this increased significantly with age to 43.8% in people 50 and older. Over half (51%) of MSI was classified as moderate, 30% as mild and 19% as severe. The war in Syria was identified as the direct cause for 8% of people with MSI. The majority (56%) of MSI diagnoses were acquired non-traumatic causes. There was high unmet need for rehabilitation services; for example, 83% of people with MSI could benefit from physiotherapy but were not receiving this service. Overall, 19% of people with MSI had an unmet need for at least one AP. Apart from availability of walking sticks/canes, coverage was low with less than half the people with MSI who needed APs and services had received them. The most common reasons for not seeking services and APs were ‘need not felt’, lack of service availability and of awareness of services, and financial barriers.

Conclusions

MSI is common among the Syrian refugee population living in Sultanbeyli District, particularly older adults, however less than half have been able to access relevant services and APs. These findings can inform the planning of health services for migrant populations, including the essential integration of rehabilitation and APs, and increase access to these vital services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00362-9.

Prevalence of common mental disorders among Syrian refugee children and adolescents in Sultanbeyli district, Istanbul: results of a population-based survey

AIMS

Research demonstrates elevated levels of common mental disorders among Syrian refugees, but the majority of studies have, to date, focused on adult populations. This study aims to estimate the prevalence of depression, anxiety and post-traumatic stress disorder (PTSD) among Syrian children and adolescents living in Sultanbeyli district of Istanbul, Turkey.

METHODS

A population-based survey among Syrian children and adolescents aged 8-17 years living in Sultanbeyli district was conducted in 2019, as part of an all-age survey of disability. 80 clusters of 50 participants (all-ages) were selected from the local municipality's refugee registration database using probability proportionate to size sampling. Children aged 8-17 years were assessed for symptoms of common mental disorders using the Child Revised Impact of Event Scale (CRIES-8) and abbreviated versions of the Center for Epidemiologic Studies Depression Scale for Children (CES-DC) and the Screen for Child Anxiety Related Disorders (SCARED).

RESULTS

Of the 852 participants, 23.7% (95% CI 19.9-27.2) screened positive for symptomatic depression, PTSD and anxiety. The prevalence estimates for depression, PTSD and anxiety were 12.5% (95% CI 9.8-15.6), 11.5% (95% CI 9.1-14.4) and 9.2% (95% CI 6.8-12.1), respectively. Depression and PTSD were significantly more common in older adolescents, whilst anxiety and PTSD were significantly more common in girls. Depression was more common in children from poorer households and those who had received no education. Children coming from larger households were less likely to show symptoms of PTSD.

CONCLUSIONS

Syrian refugee children and adolescents are vulnerable to common mental disorders, and culturally appropriate prevention and intervention support are needed for this population.

Estimating assistive product need in Cameroon and India: results of population-based surveys and comparison of self-report and clinical impairment assessment approaches

OBJECTIVES

To estimate population need and coverage for distance glasses, hearing aids and wheelchairs in India and Cameroon, and to explore the relationship between assistive product (AP) need measured through self-report and clinical impairment assessment.

METHODS

Population-based surveys of approximately 4000 people each were conducted in Mahabubnagar district, India and Fundong district, Cameroon. Participants underwent standardised vision, hearing and musculoskeletal impairment assessment to assess need for distance glasses, hearing aids, wheelchairs. Participants with moderate or worse impairment and/or self-reported difficulties in functioning were also asked about their self-reported AP need.

RESULTS

6.5% (95% CI 5.4-7.9) in India and 1.9% (95% CI 1.5-2.4) in Cameroon of the population needed at least one of the three APs based on moderate or worse impairments. Total need was highest for distance glasses [3.7% (95% CI 2.8-4.7) India; 0.8% (95% CI 0.5-1.1), Cameroon] and lowest for wheelchairs (0.1% both settings; 95% CI 0.03-0.3 India, 95% CI 0.04-0.3 Cameroon). Coverage for each AP was below 40%, except for distance glasses in India, where it was 87% (95% CI 77.1-93.0). The agreement between self-report and clinical impairment assessment of AP need was poor. For instance, in India, 60% of people identified through clinical assessment as needing distance glasses did not self-report a need. Conversely, in India, 75% of people who self-reported needing distance glasses did not require one based on clinical impairment assessment.

CONCLUSIONS

There is high need and low coverage of three APs in two low-and middle-income settings. Methodological shortcomings highlight the need for improved survey methods compatible with the international classification of functioning, disability and health to estimate population-level need for AP and related services to inform advocacy and planning.

Association of anxiety and depression with physical and sensory functional difficulties in adults in five population-based surveys in low and middle-income countries

Background

The aim of this study was to assess the association between anxiety and depression with physical and sensory functional difficulties, among adults living in five low and middle-income countries (LMICs).

Methods and findings

A secondary data analysis was undertaken using population-based disability survey data from five LMICs, including two national surveys (Guatemala, Maldives) and 3 regional/district surveys (Nepal, India, Cameroon). 19,337 participants were sampled in total (range 1,617–7,604 in individual studies). Anxiety, depression, and physical and sensory functional difficulties were assessed using the Washington Group Extended Question Set on Functioning. Age-sex adjusted logistic regression analyses were undertaken to assess the association of anxiety and depression with hearing, visual or mobility functional difficulties.

The findings demonstrated an increased adjusted odds of severe depression and severe anxiety among adults with mobility, hearing and visual functional difficulties in all settings (with ORs ranging from 2.0 to 14.2) except for in relation to hearing loss in India, the Maldives and Cameroon, where no clear association was found. For all settings and types of functional difficulties, there was a stronger association with severe anxiety and depression than with moderate. Both India and Cameroon had higher reported prevalences of physical and sensory functional difficulties compared with Nepal and Guatemala, and weaker associations with anxiety and depression.

Conclusion

People with physical and sensory functional difficulties are more likely to report experiencing depression and anxiety. This evidence supports the need for ensuring a good awareness of mental health among those working with individuals with physical and sensory functional difficulties in LMICs. This implies that these practitioners must have the skills to identify anxiety and depression. Furthermore, mental health services must be available and accessible to patients with these conditions, which will likely require further programmatic scale-up in these LMIC settings.

Multidimensional poverty and disability: A case control study in India, Cameroon, and Guatemala

Although the association between disability and multidimensional poverty has been consistently found in several studies in Low- and Middle-Income Countries. None of these studies so far has used an extended and internationally comparable questionnaire (extended Washington Group Questionnaire) and a clinical screening of disability. The purpose of this article is to calculate, compare and analyse the levels of multidimensional poverty of people with and without disabilities in Guatemala (national), in one district of Cameroon (Fundong Health District, North West Cameroon) and in one district in India (Mahbubnagar District, Telangana State). We used a case-control study approach; adults with disabilities identified in a population-based disability survey using the Washington Group Extended Questionnaire were matched to age-sex matched controls without disabilities and interviewed about their levels of access and use of different social services. Following the Alkire-Foster method, the levels of multidimensional poverty between cases and control were computed and compared. Additionally, we analysed how disability and other individual characteristics are associated with being poor in each country. The results showed that people with disabilities in all three-study settings face significantly higher levels of poverty and the intensity of their poverty is higher. In the case of Cameroon, differences in the levels of deprivation between people with and without disabilities were smaller than those observed in India and Guatemala. This might suggest that in countries with higher levels of human, economic and social development people with disabilities are being left behind by public policies aiming to reduce poverty and deprivation in basic indicators. In addition, indicators related to health contributed the most to the levels of multidimensional poverty for people with disabilities. These findings provide important evidence about the association of multidimensional poverty and disability and underline the importance of including indicators capturing individual deprivations to analyse poverty for this group.

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Case control study analysing the levels of multidimensional poverty of people with and without disabilities in one province of India, Cameroon and in Guatemala.

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People with disabilities in the three countries have higher levels of multidimensional poverty and deprivation.

Field test of the Rapid Assessment of Hearing Loss survey protocol in Ntcheu district, Malawi

Objective: (1) To test the feasibility of the Rapid Assessment of Hearing Loss (RAHL) survey protocol in Malawi (Ntcheu); (2) To estimate the prevalence and probable causes of hearing loss (adults 50+).Design: Cross-sectional population-based survey.Study sample: Clusters (n = 38) were selected using probability-proportionate-to-size-sampling. Within each cluster, 30 people aged 50+ were selected using compact-segment-sampling. All participants completed smartphone-based audiometry (hearTest). Prevalence was estimated using WHO definitions (PTA of thresholds 0.5, 1, 2, 4 kHz in the better ear of >25 dB HL (any) and >40 dB HL (≥moderate)). Otoscopy and questionnaire were used to assess probable causes. Participants with hearing loss and/or ear disease were asked about care-seeking and barriers.Results: Four teams completed the survey in 24 days. 1080 of 1153 (93.7%) participants were examined. The median time to complete the protocol was 24 min/participant. Prevalence of hearing loss was 35.9% (95% CI = 31.6-40.2) (any level); and 10.0% (95% CI = 7.9-12.5) (≥moderate). The majority was classified as probable sensorineural. Nearly one third of people (30.9%) needed diagnostic audiology services and possible hearing aid fitting. Hearing aid coverage was <1%. Lack of perceived need was a key barrier.Conclusion: The RAHL is simple, fast and provides information about the magnitude and probable causes of hearing loss to plan services.

Field test of the Rapid Assessment of Hearing Loss survey protocol in Ntcheu district, Malawi

Objective: (1) To test the feasibility of the Rapid Assessment of Hearing Loss (RAHL) survey protocol in Malawi (Ntcheu); (2) To estimate the prevalence and probable causes of hearing loss (adults 50+).Design: Cross-sectional population-based survey.Study sample: Clusters (n = 38) were selected using probability-proportionate-to-size-sampling. Within each cluster, 30 people aged 50+ were selected using compact-segment-sampling. All participants completed smartphone-based audiometry (hearTest). Prevalence was estimated using WHO definitions (PTA of thresholds 0.5, 1, 2, 4 kHz in the better ear of >25 dB HL (any) and >40 dB HL (≥moderate)). Otoscopy and questionnaire were used to assess probable causes. Participants with hearing loss and/or ear disease were asked about care-seeking and barriers.Results: Four teams completed the survey in 24 days. 1080 of 1153 (93.7%) participants were examined. The median time to complete the protocol was 24 min/participant. Prevalence of hearing loss was 35.9% (95% CI = 31.6-40.2) (any level); and 10.0% (95% CI = 7.9-12.5) (≥moderate). The majority was classified as probable sensorineural. Nearly one third of people (30.9%) needed diagnostic audiology services and possible hearing aid fitting. Hearing aid coverage was <1%. Lack of perceived need was a key barrier.Conclusion: The RAHL is simple, fast and provides information about the magnitude and probable causes of hearing loss to plan services.

Validity of hearing screening using hearTest smartphone-based audiometry: performance evaluation of different response modes

Objective: To investigate the validity of hearing screening with hearTest smartphone-based audiometry and to specify test duration addressing the two response modes and hearing loss criteria.Design: A diagnostic accuracy study comparing hearing screening with conventional audiometry.Study sample: Three hundred and forty individuals, aged between 5-92 years.Results: Of the 340 participants, 301 undertook all test procedures (273 adults and 28 children). Sensitivity and specificity were >90% for hearTest hearing screening to identify disabling hearing loss for both response modes with adults and children. We found similar sensitivity in identifying any level of hearing loss for both response modes in children, with specificity >80%, and for the self-test mode in adults. Low specificity was observed when identifying any level of hearing loss in adults using the test-operator mode. In adults, there was a significant difference between test duration for the test-operator and self-test modes.Conclusion: Hearing screening using hearTest smartphone-based audiometry is accurate for the identification of both disabling hearing loss and any level of hearing loss in adults and children in the self-test response mode. The test-operator mode is also an option for children; however, it does not provide good accuracy in identifying mild level of hearing loss in adults.

Field-testing of a rapid survey method to assess the prevalence and causes of hearing loss in Gao'an, Jiangxi province, China

BACKGROUND

The Rapid Assessment of Hearing Loss (RAHL) survey protocol aims to measure the prevalence and causes of hearing loss in a low cost and rapid manner, to inform planning of ear and hearing services. This paper reports on the first field-test of the RAHL in Gao'an County, Jiangxi Province, China. This study aimed to 1) To report on the feasibility of RAHL; 2) report on the estimated prevalence and causes of hearing loss in Gao'an.

METHODS

A cross-sectional population-based survey was conducted in September-October 2018. Forty-seven clusters in Gao'an County were selected using probability-proportionate-to-size sampling. Within clusters, compact segment sampling was conducted to select 30 people aged 50+. A questionnaire was completed covering sociodemographics, hearing health, and risk factors. Automated pure-tone audiometry was completed for all participants, using smartphone-based audiometry (hearTest), at 0.5, 1, 2, 4 kHz (kHz). All participants had their ears examined by an Ear Nose and Throat (ENT) doctor, using otoscopy, and probable causes of hearing loss assigned. Prevalence estimates were age and sex standardised to the Jiangxi population. Feasibility of a cluster size of 30 was examined by assessing the response rate, and the proportion of clusters completed in 1 day.

RESULTS

1344 of 1421 eligible participants completed the survey (94.6%). 100% of clusters were completed in 1 day. The survey was completed in 4.5 weeks. The prevalence of moderate or greater hearing loss (pure-tone average of 0.5, 1, 2, 4 kHz of > = 41dBHL in the better ear) was 16.3% (95% CI = 14.3, 18.5) and for any level of hearing loss (pure-tone average of > = 26dBHL in the better ear) the prevalence was 53.2% (95% CI = 49.2, 57.1). The majority of hearing loss was due to acquired sensorineural causes (91.7% left; 92.1% right). Overall 54.0% of the population aged 50+ (108,000 people) are in need of diagnostic audiology services, 3.4% were in need of wax removal (7000 people), and 4.8% were in need of surgical services (9500 people). Hearing aid coverage was 0.4%.

CONCLUSION

The RAHL survey protocol is feasible, demonstrated through the number of people examined per day, and the high response rate. The survey was completed in a much shorter period than previous all-age surveys in China. Some remaining challenges included assignment of causes of probable sensorineural loss. The data obtained from this survey can be used to scale-up hearing services in Gao'an.

Rationale and feasibility of a combined rapid assessment of avoidable blindness and hearing loss protocol

Purpose

This study has two main objectives: 1) to assess the value of combining the rapid assessment of avoidable blindness (RAAB) and the recently developed rapid assessment of hearing loss (RAHL) based on existing population-based data from Cameroon andIndia; 2) to test the feasibility of a combined RAAB-RAHL protocol.

Methods

A secondary data analysis of population-based disability surveys in India and Cameroon (in 2013–2014) was conducted, focussing on people aged 50+. Hearing impairment (HI) was defined as pure tone average of ≥41dB (better ear).Visual impairment (VI) was defined as presenting visual acuity of <6/18 (better eye). The relationship between HI and VI was examined. The feasibility of a combined RAAB-RAHL survey was assessed within a RAHL conducted among adults aged 50+ in Malawi in 2018. Outcomes included: time taken, costs, number of people examined in a day, and qualitative feedback from participants and field teams.

Results

The prevalence of combined VI and HI among people aged 50+ was 4.4% (95% confidence interval (CI) 3.0, 6.4) in India and 4.8% (95%CI 3.0, 8.0) in Cameroon. Among participants with VI, approximately a third in India (29.3%) and Cameroon (35.1%) also had HI. A quarter of participants in India (25.4%) and Cameroon (26.9%) who had HI also had VI. In Malawi, the total time taken to complete both RAAB and RAHL assessments was approximately 27 minutes per participant. It was feasible to complete 30 participants per day for a team of four people. The estimated cost of a combined RAAB-RAHL approach in comparison to two separate impairment surveys is up to 37% less depending on the method of combination.

Conclusion

The substantial overlap between VI and HI supports a combined rapid survey of the two impairments. The pilot study of a combined RAAB-RAHL survey demonstrates feasibility and lower cost compared to conducting two standalone impairment surveys. A combined RAAB-RAHL approach could maximize limited resources to increase prevalence data for both vision and hearing impairment.

Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review

BACKGROUND

One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC.

METHODS

We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care.

RESULTS

The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments.

CONCLUSION

Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.

An Intervention to Improve Uptake of Referrals for Children with Ear Disease or Hearing Loss in Thyolo District, Malawi: Acceptability and Feasibility

(1) Introduction: Poor uptake of referral for ear and hearing services in Malawi has been demonstrated in previous research. A multi-component educational intervention was developed to address poor uptake. The aim of this study was to explore the feasibility and acceptability of the intervention. In addition, we aimed to provide a case study of an intervention development and feasibility testing process in preparation for a potential randomised trial. (2) Methods: The intervention included three components: (i) an information booklet; (ii) personalised counselling by a community health worker and an expert mother; (iii) a text message reminder. To assess feasibility, the counselling and information booklet were provided for caregivers of eligible children (<18 years) at ear and hearing outreach camps in Thyolo. Text message reminders were sent to caregivers after the camps. After 4 weeks, all caregivers were revisited and completed a structured questionnaire and a subset were interviewed in-depth. (3) Results: 30 children were recruited, and 53% took up the referral. Interviews found counselling with a booklet was acceptable. It provided motivation, enabled a two-way conversation, and helped dispel fear. It allowed information to be shared with social networks, initiating conversations about raising funds. The text message reminder was reported to be a valued prompt. Challenges to feasibility included low network coverage, and time needed for counselling. Residual barriers included the costs of transportation. The cost was £3.70/camp. (4) Conclusions: The study found that counselling with an information booklet was feasible and acceptable. The process of testing the feasibility of the intervention identified some adaptations to the intervention components and delivery which could be implemented before it is tested in a trial. This study highlighted the value of the feasibility testing process.

Barriers to accessing cancer services for adults with physical disabilities in England and Wales: an interview-based study

OBJECTIVES

The aim of this study was to explore the barriers to accessing cancer services faced by adults with pre-existing physical disabilities.

DESIGN

Cross-sectional, exploratory qualitative study. Data were collected by semistructured interviews and analysed thematically.

SETTING

Participants were recruited through statutory and third sector organisations in England and Wales between October 2017 and October 2018.

PARTICIPANTS

18 people with a diagnosis of cancer and a pre-existing physical disability.

RESULTS

The findings illustrate that people with physical disabilities in England and Wales face a variety of barriers to accessing cancer services. The overall theme that emerged was that participants experienced a lack of attitudinal and institutional preparation both from healthcare professionals and healthcare facilities. This overall theme is illustrated through three subthemes: lack of acknowledgment of disability, unseeing disability and physical inaccessibility.

CONCLUSIONS

As the population ages and increasing numbers of people live with cancer and disability, it is important to develop knowledge to respond to the needs of this population. The mere existence of services does not guarantee their usability. Services need to be relevant, flexible, and accessible and offered in a respectful manner. It is important that healthcare professionals work towards inclusive healthcare provision, enabling the utilisation of services by all. Necessary steps to be taken include better communication between the various professionals and across the different teams involved in patients' care, raising awareness of how physical disability can affect or interact with cancer-related treatment and creating more accessible physical environments.

Children with hearing impairment in Malawi, a cohort study

Objective

To assess the outcomes of children diagnosed with hearing impairment 3 years earlier in terms of referral uptake, treatment received and satisfaction with this treatment, and social participation.

Methods

We conducted a population-based longitudinal analysis of children with a hearing impairment in two rural districts of Malawi. Key informants within the community identified the cohort in 2013 (baseline). Informants clinically screened children at baseline, and by questionnaires at baseline and follow-up in 2016. We investigated associations between sociodemographic characteristics and outcomes by multivariate logistic regression.

Results

We diagnosed 752 children in 2013 as having a hearing impairment and traced 307 (40.8%) children of these for follow-up in 2016. Referral uptake was low (102/184; 55.4%), more likely among older children (odds ratio, OR: 3.5; 95% confidence interval, CI: 1.2–10.2) and less likely for those with an illiterate caregiver (OR: 0.5; 95% CI: 0.2–0.9). Few of the children who attended hospital received any treatment (33/102; 32.4%) and 63.6% (21/33) of caregivers reported satisfaction with treatment. Difficulty making friends and communicating needs was reported for 10.0% (30/299) and 35.6% (107/301) of the children, respectively. Lack of school enrolment was observed for 29.5% (72/244) of children, and was more likely for older children (OR: 28.6; 95% CI: 10.3–79.6), girls (OR: 2.4; 95% CI: 1.2–4.8) and those with an illiterate caregiver (OR: 2.1; 95% CI: 1.0–4.1).

Conclusion

More widespread and holistic services are required to improve the outcomes of children with a hearing impairment in Malawi.

Barriers and Facilitators to Accessing Health Services: A Qualitative Study Amongst People with Disabilities in Cameroon and India

Background: Article 25 of the UNCRPD stipulates the right of people with disabilities to the highest attainable standard of health, and the timely uptake of appropriate health and rehabilitation services. This study seeks to explore the factors which influence access to health care among adults with disabilities in Cameroon and India. Methods: A total of 61 semi-structured interviews were conducted with a purposive sample of adults with vision, hearing or musculoskeletal impairments, using data from an earlier cross-sectional disability survey. In addition, 30 key informants were interviewed to provide contextual information about the local services and context. Results: Key themes included individual-level factors, understanding and beliefs about an impairment, and the nature of the impairment and interaction with environmental factors. At the community and household level, key themes were family dynamics and attitudes, economic factors, social inclusion and community participation. Intersectionality with gender and age were cross-cutting themes. Trust and acceptability of health service providers in India and poor understanding of referral processes in both countries were key service-level themes. Conclusions: The interaction of environmental and personal factors with the impairment and their levels of participation and inclusion in community structures, all contributed to the take up of services. This study illustrated the need for a multi-faceted response to improve access to health services for people with disabilities.

Improving nutritional status of children with Cerebral palsy: a qualitative study of caregiver experiences and community-based training in Ghana

BACKGROUND

Cerebral palsy (CP) is the most common childhood disability worldwide, and evidence shows that children with CP are at an increased risk of malnutrition due to feeding difficulties. This qualitative study explores caregiver experiences of feeding before and after a community-based training program in Ghana.

METHODS

Thirteen caregivers of children with CP, who were severely undernourished, were interviewed at the start of the training program. Eleven of these were interviewed again after a year of monthly group trainings and home visits, which included guidance on feeding. Four additional caregivers were interviewed at end line. Interviews explored caregivers' mealtime experiences, as well as a 24-hr dietary recall and a structured feeding observation checklist. Children's nutritional status was assessed by anthropometry.

RESULTS

Caregivers found mealtimes stressful due to time demands, messiness, and the pressure of providing enough quality food. They felt that the training program had helped reduced this stress and dietary recall data suggested some improved dietary quality. However, there was neither improvement nor deterioration in anthropometric status of the children.

CONCLUSION

Group trainings were welcomed by caregivers and notably reduced stress around feeding times. However, future work is needed in order to improve anthropometric outcomes, including, but not limited to, greater focus on nutritional requirements during caregiver training interventions. Therapeutic feeding programs must also be better utilized and need to be better equipped to care for this group of children, including deviating from standard admission and treatment protocols.

Can we achieve universal health coverage without a focus on disability? Results from a national case-control study in Guatemala

OBJECTIVE

To compare access to healthcare services for people with disabilities to those without disabilities, within a national case-control study in Guatemala.

METHODS

We undertook a population-based case-control study, nested within a national survey in Guatemala. Cases with disabilities were people with self-reported difficulties in functioning. One control without disabilities was selected per case, matched by age, gender and cluster. Information was collected on: health status, access to health services and rehabilitation, and socioeconomic status.

RESULTS

The study included 707 people with disabilities, and 465 controls. People with disabilities were more likely to report a serious health problem (aOR 2.8, 2.2-3.7) or doctor-diagnosis of one of 17 general health conditions (aOR 2.9, 2.2-3.8) as compared to controls without disabilities. People with disabilities were twice as likely as controls to have received treatment for a diagnosed condition (aOR 2.2, 1.7-2.8). Coverage of treatment for impairment-related health conditions was low, as was awareness and access to rehabilitation services. People with disabilities were more likely than controls to report being disrespected (aOR 1.9, 1.0-3.7) or finding it difficult to understand information given (aOR 1.6, 1.1-1.4).

CONCLUSION

Efforts are needed to raise awareness about rehabilitation services and improve quality of health services for people with disabilities in Guatemala, to ensure that their rights are fulfilled and to assist in the achievement of Universal Health Coverage. Better tools are needed to measure healthcare access, including consideration of geographic access, quality and affordability, to allow the generation of comparable data on access to healthcare among people with disabilities.

Evaluating the impact of a community-based parent training programme for children with cerebral palsy in Ghana

BACKGROUND

In low and middle-income settings, where access to support and rehabilitation services for children with disabilities are often lacking, the evidence base for community initiatives is limited. This study aimed to explore the impact of a community-based training programme for caregivers of children with cerebral palsy in Ghana.

METHODS

A pre and post evaluation of an 11-month participatory training programme ("Getting to Know Cerebral Palsy") offered through a parent group model, was conducted. Eight community groups, consisting of a total of 75 caregivers and their children with cerebral palsy (aged 18 months-12 years), were enrolled from 8 districts across Ghana. Caregivers were interviewed at baseline, and again at 2 months after the completion of the programme, to assess: quality of life (PedsQL™ Family Impact Module); knowledge about their child's condition; child health indicators; feeding practices. Severity of cerebral palsy, reported illness, and anthropometric measurements were also assessed.

RESULTS

Of the child-caregiver pairs, 64 (84%) were included in final analysis. There were significant improvements in caregiver quality of life score (QoL) (median total QoL 12.5 at baseline to 51.4 at endline, P<0.001). Caregivers reported significant improvements in knowledge and confidence in caring for their child (p<0.001), in some aspects of child feeding practices (p<0.001) and in their child's physical and emotional heath (p< 0.001). Actual frequency of reported serious illness over 12-months remained high (67%) among children, however, a small reduction in recent illness episodes (past 2 weeks) was seen (64% to 50% p < 0.05). Malnutrition was common at both time points; 63% and 65% of children were classified as underweight at baseline and endline respectively (p = 0.5).

CONCLUSION

Children with cerebral palsy have complex care and support needs which in low and middle-income settings need to be met by their family. This study demonstrates that a participatory training, delivered through the establishment of a local support group, with an emphasis on caregiver empowerment, resulted in improved caregiver QoL. Despite less effect on effect on child health and no clear effect on nutritional status, this alone is an important outcome. Whilst further development of these programmes would be helpful, and is underway, there is clear need for wider scale-up of an intervention which provides support to families.

Children with cerebral palsy in Ghana: malnutrition, feeding challenges, and caregiver quality of life

AIM

To assess feeding difficulties and nutritional status among children with cerebral palsy (CP) in Ghana, and whether severity of feeding difficulties and malnutrition are independently associated with caregiver quality of life (QoL).

METHOD

This cross-sectional survey included 76 children with CP (18mo-12y) from four regions of Ghana. Severity of CP was classified using the Gross Motor Function Classification System and anthropometric measures were taken. Caregivers rated their QoL (using the Pediatric Quality of Life Inventory Family Impact Module) and difficulties with eight aspects of child feeding. Logistic regression analysis explored factors (socio-economic characteristics, severity of CP, and feeding difficulties) associated with being underweight. Linear regression was undertaken to assess the relationship between caregiver QoL and child malnutrition and feeding difficulties.

RESULTS

Poor nutritional status was common: 65% of children aged under 5 years were categorized as underweight, 54% as stunted, and 58% as wasted. Reported difficulties with child's feeding were common and were associated with the child being underweight (odds ratio 10.7, 95% confidence interval 2.3-49.6) and poorer caregiver QoL (p<0.001). No association between caregiver QoL and nutritional status was evident.

INTERPRETATION

Among rural, low resource populations in Ghana, there is a need for appropriate, accessible caregiver training and support around feeding practices of children with CP, to improve child nutritional status and caregiver well-being.

WHAT THIS PAPER ADDS

Malnutrition is very common among children with cerebral palsy in this rural population in Ghana. Feeding difficulties in this population were strongly associated with being underweight. Feeding difficulties were associated with poorer caregiver quality of life (QoL). Child nutritional status was not associated with caregiver QoL.

Access to water and sanitation among people with disabilities: results from cross-sectional surveys in Bangladesh, Cameroon, India and Malawi

OBJECTIVES

To assess access to adequate water, sanitation and hygiene (WASH) among people with disabilities at the household and individual level.

DESIGN

Cross-sectional surveys.

SETTING

Data were included from five district-level or regional-level surveys: two in Bangladesh (Bangladesh-1, Bangladesh-2), and one each in Cameroon, Malawi and India.

PARTICIPANTS

99 252 participants were sampled across the datasets (range: 3567-75 767), including 2494 with disabilities (93-1374).

OUTCOME

Prevalence of access to WASH at household and individual level.

DATA ANALYSIS

Age/sex disaggregated disability prevalence estimates were calculated accounting for survey design. The Unicef/WHO Joint Monitoring Programme definitions were used to classify facilities as improved/unimproved. Multivariable logistic regression was undertaken to compare between households with/without a person with a disability, and to identify predictors of access among people with disabilities.

RESULTS

There were no differences in access to improved sanitation or water sources between households with/without members with disabilities across the datasets. In Bangladesh-2, households including a person with a disability were more likely to share facilities with other households (OR 1.3, 95% CI 1.1 to 1.5). Households with people with disabilities were more likely to spend >30 min (round-trip) collecting drinking water than households without in both Cameroon (OR 1.8, 95% CI 1.0 to 3.4) and India (OR 2.3, 95% CI 1.2 to 4.7). Within households, people with disabilities reported difficulties collecting water themselves (23%-80% unable to) and accessing the same sanitation facilities as other household members, particularly without coming into contact with faeces (up to 47% in Bangladesh-2). These difficulties were most marked for people with more severe impairments.

CONCLUSIONS

People with disabilities may not have poorer access to WASH at the household level, but may have poorer quality of access within their households. Further programmatic work is needed to ensure WASH facilities are inclusive of people with disabilities.

Exploring the links between water, sanitation and hygiene and disability; Results from a case-control study in Guatemala

OBJECTIVE

To assess the Water, Sanitation and Hygiene (WASH) access and appropriateness of people with disabilities compared to those without, in Guatemala.

METHODS

A case-control study was conducted, nested within a national survey. The study included 707 people with disabilities, and 465 age- and sex-matched controls without disabilities. Participants reported on WASH access at the household and individual level. A sub-set of 121 cases and 104 controls completed a newly designed, in-depth WASH questionnaire.

RESULTS

Households including people with disabilities were more likely to use an improved sanitation facility compared to control households (age-sex-adjusted OR: 1.7, 95% CI 1.3-2.5), but otherwise there were no differences in WASH access at the household level. At the individual level, people with disabilities reported greater difficulties in relation to sanitation (mean score 26.2, SD 26.5) and hygiene access and quality (mean 30.7, SD 24.2) compared to those without disabilities (15.5, 21.7, p<0.001; 22.4, 19.1, p<0.01). There were no differences in different aspects of water collection between people with and without disabilities in this context where over 85% of participants had water piped into their dwelling. Among people with disabilities, older adults were more likely to experience difficulties in hygiene and sanitation than younger people with disabilities.

CONCLUSIONS

People with disabilities in Guatemala experience greater difficulties in accessing sanitation facilities and practicing hygienic behaviours than their peers without disabilities. More data collection is needed using detailed tools to detect these differences, highlight which interventions are needed, and to allow assessment of their effectiveness.

Systematic review of strategies to increase access to health services among children over five in low- and middle-income countries

BACKGROUND

The populations of many low- and middle-income countries (LMIC) are young. Despite progress made towards achieving Universal Health Coverage and remarkable health gains, evidence suggests that many children in LMIC are still not accessing needed healthcare services. Delayed or lack of access to health services can lead to a worsening of health and can in turn negatively impact a child's ability to attend school, and future employment opportunities.

METHODS

We conducted a systematic review to assess the effectiveness of interventions aimed at increasing access to health services for children over 5 years in LMIC settings. Four electronic databases were searched in March 2017. Studies were included if they evaluated interventions that aimed to increase: healthcare utilisation, immunisation uptake and compliance with medication/referral. Randomised controlled trials and non-randomised study designs were included in the review. Data extraction included study characteristics, intervention type and measures of access to health services for children above 5 years of age. Study outcomes were classified as positive, negative, mixed or null in terms of their impact on access outcomes.

RESULTS

Ten studies met the criteria for inclusion in the review. Interventions were evaluated in Nicaragua (1), Brazil (1), Turkey (1), India (1), China (1), Uganda (1), Ghana (1), Nigeria (1), South Africa (1) and Swaziland (1). Intervention types included education (2), incentives (1), outreach (1), SMS/phone call reminders (2) and multicomponent interventions (4). All evaluations reported positive findings on measured health access outcomes; however, the quality and strength of evidence were mixed.

CONCLUSION

This review provides evidence of the range of interventions that were used to increase healthcare access for children above 5 years old in LMIC. Nevertheless, further research is needed to examine each of the identified intervention types and the influence of contextual factors, with robust study designs. There is also a need to assess the cost-effectiveness of the interventions to inform decision-makers on which are suitable for scale-up in their particular contexts.

A population-based survey of visual impairment and its correlates in Mahabubnagar district, Telangana State, India

PURPOSE

To estimate the prevalence and correlates of visual impairment in Mahabubnagar district, Telangana, India.

METHODS

Fifty-one clusters of 80 people (all ages) were sampled with probability proportionate to size. Households within clusters were selected through the compact segment sampling. Visual acuity (VA) was measured with a tumbling "E" chart. An Ophthalmic Assistant or Vision Technician examined people with VA<6/12 in either eye. Other impairments (hearing, physical) were clinically assessed and self-reported functional difficulties measured using the Washington Group Extended Set. People with visual impairment and age-sex matched controls with normal vision were interviewed about poverty, employment and education.

RESULTS

4,125 people were enumerated and 3,574 screened (86.6%). The prevalence of visual impairment (VA<6/12) was 8.0% (95% CI = 6.9-9.4%) and blindness was 0.4% (0.2-0.9%), and both increased rapidly with age. Uncorrected refractive error was the leading cause of visual impairment, and cataract the leading cause of blindness. Cataract surgical coverage (proportion of all cataracts that had received surgery) was relatively low (41% of people at VA<6/60), while the post-surgery outcomes were good (81% of operated eyes had presenting VA≥6/18). Among the 287 people with visual impairment, 15% had a moderate/severe physical impairment or epilepsy and 25% had a moderate/severe hearing impairment. Self-reported difficulties in vision were relatively closely related to visual acuity. People with visual impairment were more likely to be in the poorest quartile (OR = 1.9, 95% CI = 1.0-3.4) or unemployed (5.0, 2.2-10.0), compared to controls.

CONCLUSIONS

Visual impairment was common in Mahabubnagar district, was mostly avoidable, and was correlated with poverty markers.

Poverty and disability in low- and middle-income countries: A systematic review

INTRODUCTION

Disability and poverty are believed to operate in a cycle, with each reinforcing the other. While agreement on the existence of a link is strong, robust empirical evidence substantiating and describing this potential association is lacking. Consequently, a systematic review was undertaken to explore the relationship between disability and economic poverty, with a focus on the situation in low and middle income countries (LMICs).

METHODS

Ten electronic databases were searched to retrieve studies of any epidemiological design, published between 1990-March 2016 with data comparing the level of poverty between people with and without disabilities in LMICs (World Bank classifications). Poverty was defined using economic measures (e.g. assets, income), while disability included both broad assessments (e.g. self-reported functional or activity limitations) and specific impairments/disorders. Data extracted included: measures of association between disability and poverty, population characteristics and study characteristics. Proportions of studies finding positive, negative, null or mixed associations between poverty and disability were then disaggregated by population and study characteristics.

RESULTS

From the 15,500 records retrieved and screened, 150 studies were included in the final sample. Almost half of included studies were conducted in China, India or Brazil (n = 70, 47%). Most studies were cross-sectional in design (n = 124, 83%), focussed on specific impairment types (n = 115, 77%) and used income as the measure for economic poverty (n = 82, 55%). 122 studies (81%) found evidence of a positive association between disability and a poverty marker. This relationship persisted when results were disaggregated by gender, measure of poverty used and impairment types. By country income group at the time of data collection, the proportion of country-level analyses with a positive association increased with the rising income level, with 59% of low-income, 67% of lower-middle and 72% of upper-middle income countries finding a positive relationship. By age group, the proportion of studies reporting a positive association between disability and poverty was lowest for older adults and highest for working-age adults (69% vs. 86%).

CONCLUSIONS

There is strong evidence for a link between disability and poverty in LMICs and an urgent need for further research and programmatic/policy action to break the cycle.

Reasons for low uptake of referrals to ear and hearing services for children in Malawi

BACKGROUND

Early detection and appropriate intervention for children with hearing impairment is important for maximizing functioning and quality of life. The lack of ear and hearing services in low income countries is a significant challenge, however, evidence suggests that even where such services are available, and children are referred to them, uptake is low. The aim of this study was to assess uptake of and barriers to referrals to ear and hearing services for children in Thyolo District, Malawi.

METHODS

This was a mixed methods study. A survey was conducted with 170 caregivers of children who were referred for ear and hearing services during community-based screening camps to assess whether they had attended their referral and reasons for non-attendance. Semi-structured interviews were conducted with 23 caregivers of children who did not take up their referral to explore in-depth the reasons for non-uptake. In addition, 15 stakeholders were interviewed. Thematic analysis of the interview data was conducted and emerging trends were analysed.

RESULTS

Referral uptake was very low with only 5 out of 150 (3%) children attending. Seven main interacting themes for non-uptake of referral were identified in the semi-structured interviews: location of the hospital, lack of transport, other indirect costs of seeking care, fear and uncertainty about the referral hospital, procedural problems within the camps, awareness and understanding of hearing loss, and lack of visibility and availability of services.

CONCLUSION

This study has highlighted a range of interacting challenges faced by families in accessing ear and hearing services in this setting. Understanding these context specific barriers to non-uptake of ear and hearing services is important for designing appropriate interventions to increase uptake.

Childhood disability in Malawi: a population based assessment using the key informant method

Background

Epidemiological data on childhood disability are lacking in Low and Middle Income countries (LMICs) such as Malawi, hampering effective service planning and advocacy. The Key Informant Method (KIM) is an innovative, cost-effective method for generating population data on the prevalence and causes of impairment in children. The aim of this study was to use the Key Informant Method to estimate the prevalence of moderate/severe, hearing, vision and physical impairments, intellectual impairments and epilepsy in children in two districts in Malawi and to estimate the associated need for rehabilitation and other services.

Methods

Five hundred key informants (KIs) were trained to identify children in their communities who may have the impairment types included in this study. Identified children were invited to attend a screening camp where they underwent assessment by medical professionals for moderate/severe hearing, vision and physical impairments, intellectual impairments and epilepsy.

Results

Approximately 15,000 children were identified by KIs as potentially having an impairment of whom 7220 (48%) attended a screening camp. The estimated prevalence of impairments/epilepsy was 17.3/1000 children (95% CI: 16.9–17.7). Physical impairment (39%) was the commonest impairment type followed by hearing impairment (27%), intellectual impairment (26%), epilepsy (22%) and vision impairment (4%). Approximately 2100 children per million population could benefit from physiotherapy and occupational therapy and 300 per million are in need of a wheelchair. An estimated 1800 children per million population have hearing impairment caused by conditions that could be prevented or treated through basic primary ear care. Corneal opacity was the leading cause of vision impairment. Only 50% of children with suspected epilepsy were receiving medication. The majority (73%) of children were attending school, but attendance varied by impairment type and was lowest among children with multiple impairments (38%).

Conclusion

Using the KIM this study identified more than 2500 children with impairments in two districts of Malawi. As well as providing data on child disability, rehabilitation and referral service needs which can be used to plan and advocate for appropriate services and interventions, this method study also has an important capacity building and disability awareness raising component.

Prevalence and causes of musculoskeletal impairment in Fundong District, North-West Cameroon: results of a population-based survey

OBJECTIVES

Epidemiological data on musculoskeletal conditions such as degenerative joint diseases and bone fractures are lacking in low- and middle-income countries. This survey aimed to estimate the prevalence and causes of musculoskeletal impairment in Fundong Health District, North-West Cameroon.

METHODS

Fifty-one clusters of 80 people (all ages) were selected using probability proportionate to size sampling. Households within clusters were selected by compact segment sampling. Six screening questions were asked to identify participants likely to have a musculoskeletal impairment (MSI). Participants screening positive to any screening question underwent a standardised examination by a physiotherapist to assess presence, cause, diagnosis and severity of impairment.

RESULTS

In total, 3567 of 4080 individuals enumerated for the survey were screened (87%). The all-age prevalence of MSI was 11.6% (95% CI: 10.1-13.3). Prevalence increased with age, from 2.9% in children to 41.2% in adults 50 years and above. The majority of MSI cases (70.4%) were classified as mild, 27.2% as moderate and 2.4% as severe. Acquired non-trauma comprised 67% of the diagnoses. The remainder included trauma (14%), neurological (11%), infection (5%) and congenital (3%). The most common individual diagnosis was degenerative joint disease (43%). Over one-third (38%) of individuals with MSI had never received medical care or rehabilitation for their condition.

CONCLUSIONS

This survey contributes to the epidemiological data on MSI in low- and middle-income countries. Nearly half of adults aged over 50 years had an MSI. There is a need to address the treatment and rehabilitative service gap for people with MSI in Cameroon.