Water, women and disability: Using mixed-methods to support inclusive WASH programme design in Vanuatu

Inclusion of persons living with disabilities in a district-wide sanitation programme: A cross-sectional study in rural Malawi

Community-led total sanitation (CLTS) is embraced as a key strategy to achieve universal sanitation coverage (Sustainable Development Goal 6.2). Although inclusion is identified as a predictor of CLTS success, people living with disabilities are often excluded from community sanitation programmes and there is limited research exploring CLTS participation amongst people living with disabilities. This study aims to explore the extent to which people living with disabilities participated in a CLTS intervention delivered in rural Malawi using standard approaches. This cross-sectional study was conducted in the Chiradzulu district of Malawi. A household questionnaire was administered to collect information about CLTS participation. Multivariable logistic regression was performed to compare participation in different CLTS activities between households with (n = 80) and without a member with a disability (n = 167), and between household members with (n = 55) and without a disability (n = 226). No difference in CLTS participation was observed at the household-level, but there were marked differences in CLTS participation between household members with and without a disability. Household members without a disability felt they could give more input in triggering activities (OR = 3.72, 95%CI 1.18-11.73), and reported higher participation in the transect walk (OR = 4.03, 95%CI 1.45-11.18), community action planning (OR = 2.89, 95%CI 1.36-6.13), and follow-up visits (OR = 3.37, 95%CI 1.78-6.40) compared to household members with disabilities. There was no difference in the likelihood of being invited to triggering (OR = 0.98, 95%CI 0.41-2.36), attending triggering (OR = 2.09, 95%CI 0.98-4.46), or participating in community mapping (OR = 2.38, 95%CI 0.71-7.98) between household members with and without a disability. This study revealed intra-household inequalities in CLTS participation. To improve participation in CLTS interventions, facilitators should be trained on action steps to make CLTS more inclusive. Further research could include an in-depth analysis of predictors of CLTS participation amongst people living with disabilities, including disability types, severity and age.

Feasibility study of a menstrual health behaviour change intervention for women and girls with intellectual disabilities and their caregivers for Vanuatu's humanitarian responses

The Veivanua campaign is a menstrual health intervention for people with intellectual disabilities and their caregivers in Vanuatu's humanitarian setting. The campaign was adapted from the Bishesta campaign delivered in Nepal's development setting. This feasibility study is designed to assess the feasibility and acceptability of the Veivanua campaign to understand if efficacy testing is warranted. The Veivanua campaign was delivered to a preselected group of 30 young people (individuals with intellectual disabilities) and 35 caregivers (males and females). Data were collected through several qualitative tools to allow for methods triangulation: process monitoring, post-intervention in-depth interviews with caregivers and nine young people, observation of young persons, photovoice and ranking with two young people, campaign resource ranking, and key informant interviews with staff involved in the intervention. Data were analysed thematically using Nvivo 12. Results show that the Veivanua campaign is feasible. Male and female caregivers reported an increased ability to support young people's menstrual health and greater preparedness for the next emergency. Young people understood the training and applied their learning. Key informants want to scale up the intervention in their humanitarian responses. Several changes were made to the adapted campaign, but similar outcomes were recorded in Nepal and Vanuatu. All target behaviours improved, and campaign resources were used, but many caregivers found the menstrual calendar confusing. The intervention was not delivered with fidelity but responded to the context. The campaign cost more than the Bishesta campaign because procurement was more expensive in Vanuatu. In conclusion, this is the first intervention globally, so it begins to fill a substantial gap, but more must be done. As the Veivanua campaign is feasible, it requires efficacy testing in Vanuatu. It should also be adapted to humanitarian crises in other countries to support the menstrual health of this previously excluded population.

The inclusion of disability and aging in COVID-19 hygiene behavior change interventions across low-and middle-income countries: A review using the COVID-19 Inclusive WASH Checklist

Introduction

People with disabilities and older adults face a high risk of dying from COVID-19. Handwashing with soap and sanitizing surfaces were recommended to disrupt COVID-19 transmission. Yet, in many low-and middle-income countries (LMICs), these populations have inadequate access to water, sanitation and hygiene (WASH) and are not reached by public health campaigns. The Hygiene Behavior Change Coalition (HBCC) was set up to limit the spread of COVID-19 in LMICs. Twenty organizations working across 37 countries were funded to encourage populations to adopt recommended personal hygiene behaviors. This study aims to review the inclusion of disability, aging, and caregiving in HBCC grantee interventions.

Methods

A COVID-19 Inclusive WASH Checklist, which incorporates core concepts of human rights, was developed to support the inclusion of disability, aging and caregivers in interventions. The Checklist was applied to 137 documents submitted to donors within the HBCC fund to assess inclusion. Eligible grantee programme documents related to HBCC-funded projects were identified between August 2020 and January 2021. Feedback was provided to grantees recommending how to strengthen the inclusion of disability, aging, and caregiving.

Results

Most organizations identified people with disabilities, older adults and caregivers as target groups, but targeted activities to include them were scarce. Where efforts were made, immediate needs rather than rights were addressed. For example, the construction of accessible handwashing facilities featured more prominently than ensuring the participation of these groups. Examples of the coverage of core concepts in interventions included generating data with these groups and developing interventions accordingly. Limitations to inclusion were inconsistent organizational approaches, inability to monitor media campaigns, and inadequate coverage of disability and aging in donor's grant funding mechanisms.

Conclusion

To ensure these populations benefit from efforts, they must be explicitly identified as target groups, with assigned actions that are monitored; efforts must go beyond accessible WASH services to ensure the meaningful participation of these groups. The COVID-19 Inclusive WASH Checklist supports this but requires further testing to assess its appropriateness and effectiveness.

Menstrual Health Experiences of People with Intellectual Disabilities and Their Caregivers during Vanuatu's Humanitarian Responses: A Qualitative Study

Attention to menstrual health in humanitarian responses is increasing, but evidence related to people with intellectual disabilities and their caregivers is absent. This study begins to address that. We applied purposive sampling to select 17 women and girls (aged 15-31) with intellectual disabilities, their 17 caregivers in SANMA province, Vanuatu, and seven key informants. We used in-depth interviews, PhotoVoice and ranking, and observation and analysed data thematically using Nvivo 12. We found that caregivers wished to maintain the person's safety and privacy, especially when menstruating, which reduced evacuation options. People with intellectual disabilities support requirements sometimes increased after emergencies. This meant caregivers were less able to work and recover from disasters. Caregivers requested the distribution of more reusable menstrual materials and a greater choice, including adult-sized diapers for menstruation and incontinence. Key informants noted that menstrual health interventions must always be delivered to people with intellectual disabilities and their caregivers so that menstrual health knowledge and practices exist before emergencies. We found that men and women supported people with intellectual disabilities' menstrual health, thus challenging gendered assumptions about caregiving. Efforts to achieve menstrual health for this population within disaster preparedness plans must be included. If not, families will fall further into poverty every time a disaster hits Vanuatu.

Access to Services from Persons with Disabilities in Afghanistan: Is Community Based Rehabilitation Making a Difference?

The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), ratified in 2006, states that the achievement of equal rights, empowerment, and social inclusion of people with disabilities requires comprehensive rehabilitation services involving educational, social, economic, and medical interventions, all dimensions of the World Health Organization Community based rehabilitation (CBR) matrix. CBR programs aim at achieving those goals. In the present study, we investigated whether a large scale CBR program is improving access to multiple services (namely physical therapy, assistive technology, education, employment, advocacy, and community awareness) and providing satisfactions (by measuring the reduction in unmet needs) of Afghans with disabilities. We enrolled in the study 1861 newly recruited CBR participants with disabilities from 169 villages between July 2012 and December 2013, and 1132 controls screened with disabilities randomly selected with a two-stage process within 6000 households from 100 villages in the same provinces as the CBR but outside its catchment area. Using propensity score matching (PSM) and difference in difference analysis, we estimated the differences in accessing services. There were statistically significant differences between participants and controls on the access of available services between the baseline and endline. Using PSM we also found that needs were more often met among CBR participants compared to the controls. Our study indicates that a CBR program may be an effective way to provide services for persons with disabilities even in a conflict context such as Afghanistan. It contributes to addressing the longstanding question whether CBR can actually improve the rehabilitation of persons with disabilities.

An Observational Cross-Sectional Study of Gender and Disability as Determinants of Person-Centered Medicine in Botulinum Neurotoxin Treatment of Upper Motoneuron Syndrome

The motor behaviour of patients with Upper Motor Neuron Syndrome (UMNS) is characterised by spasticity. The first-line treatment for this clinical condition is Botulinum neurotoxin A (BoNTA), but the number and key locations of muscles which need to be treated is not much discussed in the literature. Cross-sectional analysis of outpatient cohort with UMNS spasticity, who were potential candidates for BoNTA treatment, was performed. Between November 2020 and November 2021, all consecutive adult patients eligible for BoNTA treatment were enrolled. The inclusion criteria encompass UMNS spasticity (onset being ≥6 months), with disabling muscles hypertonia. Patients underwent a clinical evaluation, a comprehensive assessment with the Modified Ashworth Scale, with the Modified Rankin Scale, and a patients’ perception-centred questionnaire. In total, 68 participants were enrolled in the study, among them 40 (58.8%) were male; mean age 57.9 ± 15.1. In women, BoNTA was more frequently required for adductor group muscles, independently from potential confounders (OR = 7.03, 95%CI: 1.90–25.97). According to the pattern of disability, patients with hemiparesis more frequently need to be treated in the upper limb, whereas the diplegia/double-hemiparesis group needed to be treated more frequently at the adductor and crux muscles compared to their counterparts. UMNS spasticity in women could require more attention to be paid to the treatment of adductor muscle spasticity, potentially because the dysfunction of those muscles could influence sphincteric management, required for perineal hygiene and/or sexual life.

"The weather is not good": exploring the menstrual health experiences of menstruators with and without disabilities in Vanuatu

BACKGROUND

Menstrual health is essential for gender equality and achieving the sustainable development goals. Though currently lacking, understanding and addressing menstrual health and social related inequalities requires comparison of experiences between menstruators with and without disabilities.

METHODS

We completed a mixed-methods population-based study of water, sanitation and hygiene, disability and menstrual health in TORBA and SANMA Provinces, Vanuatu. Methods included a census, nested case-control study, in-depth interviews (IDIs), focus group discussions (FGDs), PhotoVoice and structured observations. We undertook a population census of 11,000+ households and recruited 164 menstruators with and 169 without disabilities (aged 10-45) into a nested case-control study. 20 menstruators across both groups were selected for the qualitative component.

FINDINGS

Menstruators with disabilities were five times (adjusted Odds Ratio [aOR] 5.5, 95% Confidence Interval 1.8 - 16.5) more likely to use different bathing facilities to others in the household, nearly twice as likely (1.8, 1.1 - 3.1) to miss social activities, and three times (3.0, 1.6 - 5.7) more likely to eat alone during menstruation. Menstrual restrictions were widespread for all, but collecting water and managing menstrual materials was harder for menstruators with disabilities, particularly those requiring caregivers' support. These factors negatively impacted menstruators with disabilities' comfort, safety and hygiene, yet they reported less interference of menstruation on participation.

INTERPRETATION

Negative factors affecting all menstruators disproportionately impact those with disabilities, compounding existing inequalities. Menstruators with disabilities may have reported less interference because they are accustomed to greater participation restrictions than others.

FUNDING

Australian Government's Water for Women fund and public donations.

Direct participation of people with communication disabilities in research on poverty and disabilities in low and middle income countries: A critical review

INTRODUCTION

An estimated 1 billion people with disabilities live in low and middle income countries, a population that includes people with communication disabilities (PwCD). PwCD are a heterogenous group with a wide range of abilities who may be underrepresented in research due to the communication demands involved in research participation.

METHODS

A critical analysis of 145 studies from a previously published systematic review was undertaken with the aim of documenting the opportunities for direct participation of PwCD in research on poverty and disability in low- and middle- income countries.

RESULTS

The key finding was the high risk of underrepresentation of PwCD in research on poverty and disability in LMICs, despite low rates of explicit exclusion (n = 8; 5.5%). A total of 366 uses of data collection tools were analysed (255 unique tools). The majority of data collection tools had high communication demands (92.9%), including those measuring disability (88.6%) and those assessing poverty (100%). Only 22 studies (15.2%) specifically included PwCD. A subset of these studies (n = 14) presented disaggregated data in a way that allowed for analysis of outcomes for PwCD, suggesting a clear intersection between poverty and communication disability, with findings related to general poverty indicators, reduced access to education, low levels of employment, and additional expenditure.

CONCLUSIONS

The findings suggest a systematic underrepresentation of PwCD in research on poverty and disability with substantial implications for future policy and program planning, directly affecting the availability and provision of services and resources for this population. A failure to provide adequate opportunity for participation of PwCD in research risks leaving those with communication disabilities behind in the pursuit of global poverty eradication.

"I'm scared to talk about it": exploring experiences of incontinence for people with and without disabilities in Vanuatu, using mixed methods

Background

Incontinence is the involuntary loss of urine and/or faeces. It is stigmatised and can reduce quality of life. People with incontinence require water, sanitation, hygiene (WASH) and incontinence products. People with disabilities are at risk of experiencing incontinence and may face challenges managing, however, minimal evidence exists.

Methods

This study aimed to complete a population-based study of disability in TORBA and SANMA Provinces, Vanuatu to quantify the prevalence and demographics of disability, experience of WASH access and incontinence for people with and without disabilities. We completed a survey, case-control study, in-depth interviews, structured observations and PhotoVoice. 179 people with disabilities and 148 people without disabilities completed the incontinence module in the case-control study. We applied purposeful sampling to select 27 people with and without a disability from the nested case-control, and 16 key informants for the qualitative study to further explore the impact of incontinence on people's lives.

Findings

People with disabilities were three times more likely to experience incontinence than people without disabilities (Adjusted Odds Ratio 3.3, 95% confidence interval 1.8 – 5.8). Challenges facing all people with incontinence were distance to latrines and lack of incontinence products. People with disabilities were less able to wash and participate in social activities. Less than 10% had assistive technologies; caregivers had no lifting devices. People experiencing incontinence did not disclose this to others, including medical professionals, who also did not raise the issue.

Interpretation

Inaccessible and inadequate WASH, lack of incontinence products and stigma increased isolation for all people with incontinence. Additionally, people with disabilities and caregivers faced discrimination and insufficient assistive technologies. This negatively affected their wellbeing and quality of life, and requires addressing.

Funding

Australian Government's Water for Women Fund and public donations.

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.

Are the rights of people with disabilities included in international guidance on WASH during the COVID-19 pandemic? Content analysis using EquiFrame

PURPOSE

People with disabilities are at increased risk from COVID-19. Access to water, sanitation and hygiene (WASH) services and facilities is a fundamental right for all, and is vital in stopping the transmission of COVID-19. However, people with disabilities often face difficulties accessing WASH. Various international organisations have published guidance and recommendations on WASH service provision during the COVID-19 pandemic, and this must include information of relevance to people with disabilities. This study aimed to investigate the inclusion of core concepts of rights for people with disabilities in guidance on WASH during the COVID-19 pandemic.

METHOD

We used the EquiFrame content analysis tool to analyse the inclusion of 21 core concepts of rights for people with disabilities in international guidance documents on WASH during the pandemic. 29 documents were included from multilateral entities, international consortiums and non-governmental organisations. Key information from the included guidance documents was extracted for each of the 21 core concepts.

RESULTS

One-third of the WASH guidance did not include any reference to the rights of people with disabilities, and the majority of information was provided by just one guidance document. Most commonly referenced across all was access to WASH, including details on accessible infrastructure (eg, handwashing stations) and communication strategies. Information on many important rights and considerations, such as the affordability of services and caregiver support, was rarely included.

CONCLUSION

Although some information is provided in international WASH guidance, this often has a narrow focus on access, rather than the full array of rights and considerations that are important for people with disabilities. International guidance should continue to be reviewed and updated to include further information of relevance to people with disabilities, informing a disability-inclusive approach to WASH during the remainder of the COVID-19 pandemic and future crises.