Disability as deprivation of capabilities: Estimation using a large-scale survey in Morocco and Tunisia and an instrumental variable approach

Too Little, Not Enough: Impact of Safety Nets on Food Security Among Households with Disabled Members in Nigeria

This study assessed the impact of safety nets on food insecurity in households with people with disabilities (PWD) in Nigeria. Using data from the 2019 Nigeria General Household Survey, we assessed the risk of experiencing food insecurity among households and the moderating role of safety nets using households without PWDs as a reference. PWD households were three times more likely to experience severe food insecurity compared to households without PWDs. The impact of the safety net program on the risk of food insecurity showed that receiving social benefits had little effect among households with disabled members experiencing severe food insecurity.

Urban and rural differences in needs, service use and satisfaction among caregivers of autistic children in Morocco

LAY ABSTRACT

It is very important to understand the needs of caregivers to be able to empower caregivers and to develop or improve services around the world. Therefore, research in different regions is needed to understand differences in caregivers needs between countries, but also between areas within countries. This study investigated differences in needs and service use between caregivers of autistic children in Morocco, living in urban and rural areas. A total of 131 Moroccan caregivers of autistic children took part in the study and responded to an interview survey. The results showed both similarities and differences between urban and rural living caregivers' challenges and needs. Autistic children from urban communities were much more likely to receive intervention and attend school than children from rural communities, even though age and verbal skills of the two groups of children were comparable. Caregivers expressed similar needs for improved care and education, but different challenges in caring. Limited autonomy skills in children were more challenging to rural caregivers, while limited social-communicational skills were more challenging to urban caregivers. These differences may inform healthcare policy-makers and program developers. Adaptive interventions are important to respond to regional needs, resources, and practices. In addition, the results showed the importance of addressing challenges as experienced by caregivers such as costs related to care, barriers in access to information, or stigma. Addressing these issues may help reduce both global and within-country differences in autism care.

Expenditure projections for community home-based care services for older adults with functional decline in China

INTRODUCTION

Difficulty in identifying the functional status of older adults creates an imbalance between the supply and demand for community home-based care. Using a multi-level functional classification system to guide care cost measurement may optimize care resources and meet diverse eldercare demands.

METHODS

The Markov model was used to project the older population size in different functional decline (FD) statuses. The project cost and the man-hour costing method were combined to forecast the cost of community home-based care for older adults with FD.

RESULTS

The projected cost of eldercare increased from 1668.623 billion yuan in 2020 to 2836.754 billion yuan in 2035. By 2035, the total cost for community-based home care for those in pathological development of FD statuses such as "viability disorder," "acute disease," "somatic functional disorder," and "sub-disorder" was projected to be 1094.591 billion, 433.855 billion, 1256.236 billion, and 52.072 billion yuan, respectively, which is 1.24, 1.58, 1.78, and 0.49 times higher than the results by the man-hour costing method. Family caregiving costs are about three times those of professional caregivers.

CONCLUSION

The escalating cost of providing graded care for older adults, particularly by family caregivers, presenting a significant evidence for the need to optimize resource allocation and develop a robust human resources plan for community home-based care.

The effect of PM2.5 levels on continuum functional capability among older adults: Potential cause-effect or statistical associations

BACKGROUND

Since there is limited knowledge about health effects of the clean air policy (CAP, i.e., a series of emission-control actions) on continuum functional capacity (CFC) among the older adults on a large representative data, our research was to fill this gap.

METHODS

We used a continuous variable of airborne fine particulate matter (PM_2.5) particles as a proxy for the CAP to evaluate the linear and non-linear effect of PM_2.5 exposure on CFC of older adults, under the quasi-experimental framework of the temporal contrast between 2011 (before the CAP) and 2015 (after the CAP). Multiple environmental factors were considered and spline function was utilized to fit the spatial autocorrelations. A competing risk model was constructed to qualify the impact of PM_2.5 on multidimensional disability.

RESULTS

After adjusting for potential confounders, a J-shaped association was found between PM_2.5 concentration increase on CFC, with a threshold 2μg/m³. We also demonstrated that a 10-µg/m³ increase in PM_2.5 concentration was related to a 14.0% (95% CI:0.00, 19.00%) increment risk in the functional decline. Similarly, the competing risk model presented a hazard ratio of multidimensional disability ranging from 1.707(0.928-4.141) at 40μg/m³ concentration of PM_2.5 to 4.384 (1.970-9.755) over 80μg/m³. Stratified analyses showed that married men less than 80 years old in rural areas are more likely to be affected by PM_2.5 exposure, where the influencing mechanism of air pollutant to outdoor and indoor activities might be the potential cause.

CONCLUSION

Implementing CAP might improve CFC, prevent the occurrence of disability, and update the air policy.

Multidimensional poverty of persons with disabilities in China: An analysis of poverty reduction effect of employment services

Introduction

Disability is a global public health problem, and poverty due to illness and disability has always been a major problem and challenge for global poverty governance. In order to eradicate poverty, China has carried out a series of welfare reforms and employment interventions for people with disabilities. The purpose of this study is to examine the levels of multidimensional poverty of persons with disabilities aged 16-59 in China and the poverty reduction effect of employment services.

Methods

The Alkire-Foster (AF) method is applied to measure and decompose the multidimensional poverty index (MPI) of people with disabilities in this study. In order to make the results more robust, ordinary least squares (OLS) regression and the combination of propensity score matching and difference-in-differences (PSM-DID) are used to study the effect of employment services on multidimensional poverty of the disabled.

Results

The results show that among persons with disabilities aged 16-59, about 90% are deprived in at least one dimension, and about 30% are in a state of severe multidimensional poverty until 2019. The contributions of deprivation in the dimensions of education and social participation are remarkably higher than dimensions of economy, health and insurance. In addition, employment services have a significant improvement effect on multidimensional poverty, which is reflected not only in the economic dimension, but also in the dimensions of education, insurance and social participation.

Conclusion

People with disabilities are generally in multidimensional poverty in China, and their abilities in learning and social integration are seriously inadequate. Employment services have played a great role in improving poverty, but the improvement has been different in different dimensions and different disability categories. These findings provide important evidence for recognizing multidimensional poverty of persons with disabilities and the poverty reduction effect of employment services, which will help to formulate more reasonable public policies to eradicate poverty.

Multidimensional Measures and the Extra Costs of Disability: How Are They Related?

People with disabilities are more likely than individuals without disabilities to face higher levels of deprivation and multidimensional poverty, and those deprivations might be associated with the extra costs of living with a disability. However, there has not been an analysis of how multidimensional poverty measures are related to the extra costs of disability or whether these measures can be used as a proxy of the standard of living in the analysis of the extra costs of disability. This paper aims to analyse whether multidimensional poverty measures can be used to study the extra costs of disability and, based on the capability approach, how multidimensional poverty is related to the extra costs of disability. This paper discusses theoretical, technical, and methodological aspects to be considered when studying the relationship between extra costs and multidimensional poverty, and we used data from Chile and Nigeria to illustrate this relationship. We conclude that when analysing the extra costs of disability, multidimensional measures might be an option; however, it is necessary to clearly stablish the relationship among income, deprivation, and the extra costs of disability.

Mobility impairment and life satisfaction in the Northern Region of Malawi

Background

There exist many psychosocial sequelae associated with mobility impairment, especially in low-resource settings where access to mobility assistive devices is limited.

Objectives

This study aims to (1) define the burden and presenting aetiologies of mobility impairment in the rural Northern Region of Malawi and (2) assess the relationship between physical disability, life satisfaction and access to mobility aids.

Methods

At mobility device donation clinics throughout the Northern Region of Malawi, adults living with mobility impairment were surveyed with a demographic questionnaire and a series of validated surveys to assess their physical activity levels (Global Physical Activity Questionnaire [GPAQ]), degree of mobility impairment (Washington Group Extended Set Questions on Disability) and life satisfaction (patient-reported outcomes measurement information systems satisfaction with participation in social roles and general life satisfaction).

Results

There were 251 participants who qualified for inclusion, of which 193 completed all surveys. Higher physical activity scores were positively correlated with increased life satisfaction: (1) satisfaction with participation in social roles (0.481, p < 0.0001) and (2) general life satisfaction (0.230, p < 0.001). Respondents who had previously used a formal mobility device reported 235.5% higher physical activity levels ([139.0%, 333.0%], p = 0.006), significantly higher satisfaction with participation in social roles ([0.21, 6.67], p = 0.037) and equivocally higher general life satisfaction ([-1.77, 3.84], p = 0.470).

Conclusion

Disability and mental health do not exist in isolation from one another. Given the positive correlations between formal mobility device usage and both physical activity and life satisfaction, interventions that increase access to mobility-assistive devices in undertreated populations are imperative.

Contribution

This study contributes to the understanding of the complex relationship between physical disability, access to mobility aids, and life satisfaction. Results from this study suggest the potential benefit that increasing access to mobility aids may have in improving the quality of life of mobility impaired persons in resource-limited settings, such as the Northern Region of Malawi.

Multidimensional Disability Evaluation and Confirmatory Analysis of Older Adults in a Home-Based Community in China

A robust multi-dimensional disability assessment standard was constructed to consider physical condition, care resources, and social interaction that might lead to disability, to provide a basis for accurate identification of care needs for older people aged 60 and above in a home-based community. Based on the “Capability approach” theory, the Alkire-Foster method was applied to assess the multidimensional disability. This was followed by the confirmatory analysis of the Seemingly Unrelated Regression Estimation. Adjusted Bourguignon and Chakravarty index was also calculated to analyze the sensitivity to further support our conclusions. We constructed a multi-dimensional disability indicator system by combining physical condition, care resources, and social interaction. Findings presented that the impairment of individuals' motor ability, ability to manage disease, cognitive psychology, and communication skills and social interaction contributed to multidimensional disability the most. And older people who are female, aged over 65, with lower BMI, living in rural areas, with a lower education level, getting more formal care, and with relatively higher creatinine, tend to face a higher risk of deprivation in overall multidimensional disability. Therefore, the targeted interventions to improve health literacy, nutrition, skill of disease management, social networks, and communication skills for older people and also timely detection of the abnormal changes in potential biomarker indicators of them is necessary to delay disability and prevent its occurrence.

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.

Novel subgroups of functional ability in older adults and their associations with adverse outcomes

Background

There is no general agreement on a standard form of functional classification in older adults and is mainly assessed by Activities of Daily Living (ADL) and/or Instrument Activity of Daily Living. A refined classification based on evaluation the limitations of intrinsic capacity, environment and social interaction, could provide a basis to predict the future disability and identify individuals with increased risk of adverse outcomes.

Methods

A new functional classification among older adults aged 60 and over was conducted by latent class analysis and compared with the traditional classifications, based on the China Health and Retirement Longitudinal Study. To further investigate the scientific validity of this new classification, associations with 7-year mortality and ADLs impairments among categories were tested by using Survival curves and Cox proportional hazard models. This was followed by the confirmatory analysis related to the prospective data. Competing risk analysis was also performed to analysis the sensitivity to further support our conclusions.

Results

Five categories were identified among 5,992 older adults which gave the best fitting, yielding a significant Bootstrap Likelihood Ratio Test (p < 0.001) and Lo-Mendell-Rubin adjusted likelihood ratio test (p < 0.001), with an entropy over 0.80. The presence of five categories: “health” (34.0%), “sub-disorder status” (36.6%), “acute diseases” (10.3%), “somatic functional disorder” (7.7%), and “viability disorder” (11.4%), which matched well with the functional independence rates by the international classifications. Among them, those in “sub-disorder status” were considered as an intermediate status between disability and health. The findings also revealed that those who were in “acute disease”, “somatic functional disorders”, “health” and “sub-disorder status” had a significant lower risk of mortality and ADLs limitations than “viability disorder”. And the risks gradually increased towards the less functionally independent end of the classification. However, the distribution of characteristics among five categories were in a synchronous change, indicating a stable classification.

Conclusions

A new classification representing the functional heterogeneity of older adults could effectively stratify the risk of mortality and ADLs limitations. Identifying the clusters of functional decline might be useful in predicting subsequent ageing trends, designing personalized intervention, and delaying the progression of disability and preventing its occurrence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03081-9.

Typical school-to-work transitions of young adults with disabilities in Germany - a cohort study of recipients of vocational rehabilitation services after leaving school in 2008

PURPOSE

In Germany, vocational rehabilitation (VR) for young people with disabilities (YPWD) aims to counteract disadvantages on the training and labour markets. However, the school-to-work transitions (STWT) among YPWD are underexplored. This study investigates to what extent and for whom VR provides an institutional bridge into employment.

MATERIALS AND METHODS

Based on representative administrative data of the German Federal Employment Agency, young people in VR are observed for 6.5 years after completing lower or intermediate secondary education in 2008. Using optimal matching and cluster analysis, six typical STWT trajectories are identified.

RESULTS

Most of the YPWD completed company-external vocational training, some undertook regular in-firm training. These forms of training often lead to regular employment, albeit with a delay for some. Other young people are guided from training in sheltered workshops into sheltered employment. Another group exhibits problematic STWTs in which recurring unemployment and (non-training) programmes fail to lead to training or employment.

CONCLUSIONS

VR combined with in-firm or company-external vocational training can facilitate the STWTs of people with disabilities. However, individuals from poor families are less likely to benefit from VR. Similarly, restricted capabilities and problematic STWTs are observed when young people drop out of VR due to poor cooperation.Implications for rehabilitationVocational training often is a prerequisite for labour market entry; however, if the structural conditions on the local labour market are unfavourable, young people with disabilities do not take up employment.Training within sheltered workshops often leads to highly institutionalised trajectories that should be reconsidered to permit greater permeability into the regular labour market.As young people with problematic STWT more often come from poor households, they should be targeted to a greater extent in the context of VR counselling.

Examining the Availability and Accessibility of Rehabilitation Services in a Rural District of South Africa: A Mixed-Methods Study

Introduction: Rehabilitation services aim to optimise individuals’ functioning and reduce disability. However, people with disabilities, who represent a key population of users of rehabilitation services, continue to have unmet needs for rehabilitation services that include the provision of assistive devices. This paper examines the availability and accessibility of rehabilitation services in a rural district of South Africa in order to explore why unmet needs for rehabilitation services persist. Methods: All nine district hospitals in a rural district of South Africa were included in the study. Rehabilitation services capacity was assessed by examining the available assistive devices, consumables and human resources at the level of the health facility. Data collection was conducted using the Global Co-operative Assistive Technology [GATE] Assistive Products List, AT2030’s ATScale priority list and the South African National Catalogue of Commodities for Primary Health Care Facilities. Descriptive statistics were then used for the analysis. For the qualitative component, semi-structured interviews were conducted with adults with physical disabilities at household level to explore barriers to accessing assistive device inclusive rehabilitation services and the consequences thereof in the same rural district. An interview guide based on the WHO health system building blocks was used. Thematic content analysis guided the analysis of the interview transcripts. Findings: The findings of the research demonstrate that rehabilitation service capacity in the district was constrained as a result of low availability of assistive devices [2–22%] and consumables [2–47%], as well as, possibly, a shortage of rehabilitation providers [n = 30] with an unequal distribution across health facilities [n = 9]. In addition, people with physical disabilities reported poor referral pathways, financial constraints, transport and road consideration and equipment unavailability as barriers to accessing rehabilitation services. Moreover, these barriers to access predisposed individuals to finance-, health- and person-related harm. Conclusion: Rehabilitation service availability is constrained by a lack of service capacity in rural South Africa. In addition, the rehabilitation services in district hospitals are not adequately accessible because of existing barriers to enable key populations to achieve optimised functioning.

Securing occupational rights by addressing capabilities: A professional obligation

BACKGROUND

The World Federation of Occupational Therapists asserts that all occupational therapists are obligated to promote occupational rights, and has highlighted the importance of Amartya Sen's concept of 'capabilities' to the work of securing the occupational rights to which all are equally entitled.

AIMS

To outline the capabilities approach and highlight its relevance and importance for the occupational therapy profession.

MATERIAL & METHODS

Drawing from Sen's work, and that of other scholars who have critiqued and adapted his capabilities approach, this paper describes the foundational components of the capabilities approach and identifies important overlaps with issues of concern to occupational therapy.

RESULTS

Sen's capabilities approach employs a contextualised view of human wellbeing; attending to whether people have the abilities to do the things they would value doing, and whether their circumstances actually provide the real opportunities to choose to do what they would value doing.

CONCLUSIONS

The capabilities approach, with its attention to abilities and actions, options and opportunities, empowerment and choice, justice and participation, has clear relevance for occupational therapists.

SIGNIFICANCE

A capabilities perspective provides a valuable framework for occupational therapists striving towards equalising people's opportunities, possibilities and choices - their capabilities - to secure their occupational rights.

Stigma of persons with disabilities in South Africa: Uncovering pathways from discrimination to depression and low self-esteem

Despite the fact that universal inclusion is a basic principle of the Sustainable Development Goals, the inclusion of persons with disabilities in humanitarian interventions and development policies remains elusive. Persons with disabilities face high risks of poverty, poor nutrition, limited inclusion in labor markets and poor mental health as a result. Stigma is likely to play a negative role in this regard and yet, no study has investigated the impact of stigma on depression and self-esteem of persons with disabilities. To address this gap in the literature, we conducted in June 2017 a random sample disability case control household study in Soweto, a township in Johannesburg, South Africa. Using propensity score analysis and structural equation modeling, we investigated the relationship between disability, stigma, depression and self-esteem controlling for socioeconomic covariates. Our main empirical results showed that stigma significantly mediates the association between disability and higher depression on the one hand and between disability and lower self-esteem on the other. This mediating effect exists even after controlling for age, gender, marital status, education, employment and wealth. We also found strong direct associations between disability and depressive mood, somatic indicators and negative feelings such as unhappiness and low self-esteem. Unemployment aggravates depression and low self-esteem while low education worsens self-esteem only. In addition, depression exacerbates low self-esteem. Both unemployment and low education are more common among persons with disabilities aggravating the disability, depression, poor self-esteem nexus. Similarly, persons with disabilities who are more likely to be depressed are also at higher risk of low self-esteem. These results point to a vicious reinforcing circle of exclusion from society, despair and self-deprecation, which could prove difficult to break. Substantial psycho-social support and anti-stigma policies anchored in local cultural values, engaging persons with disabilities and their communities, are required to break this vicious circle.

Empirical Validity of a Generic, Preference-Based Capability Wellbeing Instrument (ICECAP-A) in the Context of Spinal Cord Injury

BACKGROUND

Assessing the validity of generic instruments across different clinical contexts is an important area of methodological research in economic evaluation and outcomes measurement.

OBJECTIVE

Our objective was to examine the empirical validity of a generic, preference-based capability wellbeing instrument (ICECAP-A) in the context of spinal cord injury.

METHODS

This study consisted of a secondary analysis of data collected using an online cross-sectional survey. The survey included questions regarding demographics, injury classifications and characteristics, secondary health conditions, quality of life and wellbeing, and functioning in activities of daily living. Analysis comprised the descriptive assessment of Spearman's rank correlations between item-/dimension-level data for the ICECAP-A and four preference-based health-related quality of life (HRQoL) instruments, and discriminant and convergent validity approaches to examine 21 evidence-informed or theoretically derived constructs. Constructs were defined using participant and injury characteristics and responses to a range of health, wellbeing and functioning outcomes.

RESULTS

Three hundred sixty-four individuals completed the survey. Mean index score for the ICECAP-A was 0.761; 12 (3%) individuals reported full capability (upper anchor; score = 1), and there were no reports of zero capabilities (lower anchor; score = 0). The strongest correlations were dominated by items and dimensions on the comparator (HRQoL) instruments that are non-health aspects of quality of life, such as happiness and control over one's life (including self-care). Of 21 hypothesised constructs, 19 were confirmed in statistical tests, the exceptions being the exploratory hypotheses regarding education and age at injury.

CONCLUSION

The ICECAP-A is an empirically valid outcome measure for assessing capability wellbeing in people with spinal cord injury living in a community setting. The extent to which the ICECAP-A provides complementary information to preference-based HRQoL instruments is dependent on the comparator.

Disability and multidimensional quality of life: A capability approach to health status assessment

This paper offers an approach to assessing quality of life, based on Sen's (1985) theory, which it uses to understand loss in quality of life due to mobility impairment. Specifically, it provides a novel theoretical analysis that is able to account for the possibility that some functionings may increase when a person's capabilities decrease, if substitution effects are large enough. We then develop new data consistent with our theoretical framework that permits comparison of quality of life between those with a disability (mobility impairment) and those without. Empirical results show that mobility impairment has widespread rather than concentrated impacts on capabilities and is associated with high psychological costs. We also find evidence that a small number of functionings are higher for those with a disability, as our theory allows. The paper concludes by discussing possible implications for policy and health assessment methods.

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.

Social causation or social selection? The longitudinal interrelationship between poverty and depressive symptoms in China

RATIONALE

To our knowledge, no prior studies have investigated these bidirectional pathways between poverty and depressive symptoms to identify potential mechanisms.

OBJECTIVE

This study aimed to investigate the interrelationship between poverty and depressive symptoms by examining two causal theories: social causation, which claims that the condition of poverty causes mental health disorders, and social selection, which suggests that those with poor mental health are more likely to drift into poverty.

METHOD

We obtained data from 17,250 adults aged 45 years or above from the China Health and Retirement Longitudinal Studies, first conducted in 2011-2012. Participants were tracked for 4 years, with baseline measurements taken as well as two 2-year follow-up visits. Structural equation models were used to examine the pathways in two directions at baseline, 2-year follow-up and 4-year follow-up.

RESULTS

We found significant total effects and indirect effects of poverty on depressive symptoms at baseline, which were mediated through deterioration of household living conditions, decrease in social participation, and decline in life satisfaction. In the opposite direction, depressive symptoms directly led individuals to drift into poverty at baseline and at follow-up.

CONCLUSIONS

This study suggested that social causation and social selection may operate concurrently. Proactive interventions, especially ones focusing on modifiable protective factors that our findings identified as mediators in the link between poverty and depression, are urgently needed to break the vicious cycle of poverty and depression and create a virtuous cycle of increasing returns.

Analysis of Social Determinants of Health and Disability Scores in Leprosy-Affected Persons in Salem, Tamil Nadu, India

A consistent relationship has been found between leprosy and inequities in social determinants of health. It, however, remains unclear which aspect of these social determinants contributes most to the risk of infection, and even less clear are the risk factors for the development of leprosy-related disabilities. The objective of this study was to elicit the differential impact of social determinants of health in leprosy-affected persons, and determine whether structural inequities in accessibility to societal resources and lower socioeconomic parameters correlated with higher severity of disabilities. This analysis was based on a sampled population affected by leprosy in Salem, Tamil Nadu, India. Persons enrolled in the study were covered by a nongovernmental lifelong care program, had completed a multidrug therapy for leprosy and/or were slit-skin-smear negative, and showed Grade 1 or higher disabilities due to leprosy. Multiple stepwise linear regression analysis was performed. The Eyes-Hands-Feet (EHF) score was the outcome variable, and gender, age, time after release from treatment, monthly income, and living space were explanatory variables. There were 123 participants, comprised of 41 (33.33%) women and 82 (66.67%) men. All study participants belonged to India's Backward classes; 81.30% were illiterate and the average monthly income was 1252 Indian rupee (INR) (US$19.08 or €17.16). The average EHF score was 7.016 (95% CI, 6.595 to 7.437). Stepwise multiple linear regression analysis built a significant model, where F(2, 120) = 13.960, p ≤ 0.001, effect size (Cohen's f2) = 0.81, explaining 18.9% of the variance in EHF scores (R² = 0.189). Significant predictors of a higher EHF score in persons affected by leprosy were found to be higher age (beta = 0.340, 95% CI, 0.039 to 0.111, p < 0.001), as well as less living space (beta = -0.276, 95% CI, -0.041 to -0.011, p = 0.001). Our results suggest that inequalities in social determinants of health correspond to higher disability scores, which indicates that poor living standards are a common phenomenon in those living with leprosy-related disabilities. Further research is needed to dissect the exact development of impairments after release from treatment (RFT) in order to take targeted actions against disability deterioration.