Poverty and musculoskeletal impairment in Rwanda

The inequity of global healthcare in pediatric rheumatology

In pediatric rheumatology, global health inequity relates to the uneven distribution of healthcare resources, accessibility, and health outcomes among children with rheumatic conditions across various countries, regions, and socioeconomic groups. This inequity can manifest in various ways. This review article provides an overview of common rheumatic diseases, such as juvenile idiopathic arthritis and systemic lupus erythematosus, which significantly contribute to and are affected by disparities in global healthcare. Subsequently, we delve into the inequalities in accessing patient care, encompassing issues related to diagnosis and treatment. Additionally, we address challenges in educational advancement and identify research gaps within the field of pediatric rheumatology. We also reveal successful global collaborations, such as a Global Task Force for Pediatric Musculoskeletal Health and special working groups among international organizations, aimed at bridging the disparities gap. Through these efforts, we try to enhance understanding, cooperation, and resource allocation to ensure equal access to quality care worldwide for children with rheumatic conditions. Futhermore, we present a case study from Thailand, highlighting their successful initiatives in developing pediatric rheumatology within their healthcare system.

The unmet need for treatment of children with musculoskeletal impairment in Malawi

Background

More than a billion people globally are living with disability and the prevalence is likely to increase rapidly in the coming years in low- and middle-income countries (LMICs). The vast majority of those living with disability are children residing in LMICs. There is very little reliable data on the epidemiology of musculoskeletal impairments (MSIs) in children and even less is available for Malawi. Previous studies in Malawi on childhood disability and the impact of musculoskeletal impairment (MSI) on the lives of children have been done but on a small scale and have not used disability measurement tools designed for children. Therefore in this study, we aimed to estimate the MSI prevalence, causes, and the treatment need among children aged 16 years or less in Malawi.

Methods

This study was carried out as a national cross sectional survey. Clusters were selected across the whole country through probability proportional to size sampling with an urban/rural and demographic split that matched the national distribution of the population. Clusters were distributed around all 27-mainland districts of Malawi. Population of Malawi was 18.3 million from 2018 estimates, based on age categories we estimated that about 8.9 million were 16 years and younger. MSI diagnosis from our randomized sample was extrapolated to the population of Malawi, confidence limits was calculated using normal approximation.

Results

Of 3792 children aged 16 or less who were enumerated, 3648 (96.2%) were examined and 236 were confirmed to have MSI, giving a prevalence of MSI of 6.5% (CI 5.7–7.3). Extrapolated to the Malawian population this means as many as 576,000 (95% CI 505,000-647,000) children could be living with MSI in Malawi. Overall, 46% of MSIs were due to congenital causes, 34% were neurological in origin, 8.4% were due to trauma, 7.8% were acquired non-traumatic non-infective causes, and 3.4% were due to infection. We estimated a total number of 112,000 (80,000-145,000) children in need of Prostheses and Orthoses (P&O), 42,000 (22,000-61,000) in need of mobility aids (including 37,000 wheel chairs), 73,000 (47,000-99,000) in need of medication, 59,000 (35,000-82,000) in need of physical therapy, and 20,000 (6000-33,000) children in need of orthopaedic surgery. Low parents’ educational level was one factor associated with an increased risk of MSI.

Conclusion

This survey has uncovered a large burden of MSI among children aged 16 and under in Malawi. The burden of musculoskeletal impairment in Malawi is mostly unattended, revealing a need to scale up both P&O services, physical & occupational therapy, and surgical services in the country.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03113-8.

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.

Barriers experienced by people with disabilities participating in income-generating activities. A case of a sheltered workshop in Bloemfontein, South Africa

Background

People with disabilities often participate in income-generating activities (IGAs) in sheltered workshop in South Africa. However, they face many barriers that limit their ability to participate effectively in economic activities hosted by the workshops.

Objectives

To illustrate the barriers that limit the participation of people with disabilities in IGAs in a sheltered workshop.

Method

A qualitative exploratory single case study was conducted in a sheltered workshop. Eighteen participants, age 22 to 52 years with various disabilities were purposively sampled. Observations and semi-structured interview guides were used to generate data. Verbatim transcription was used after which content analysis was applied to identify ideas and concepts relating to barriers experienced by people with disabilities participating in IGAs.

Results

Some of the barriers participants experienced included institutional barriers (ability to use working tools, inability to concentrate for long periods, lack of funds, language barriers, lack of motivation, activities that are not stimulating and lack of artistry skills) and attitudinal barriers (exclusion from decision making) These barriers had an adverse influence on their performance in IGAs.

Conclusion

The study found eight different barriers that existed in a sheltered workshop which limited the participation of the people with disabilities that attended the workshop. This information can be used to develop strategies to address each barrier and promote increased participation of the individual thereby improving their quality of life.

Work Related Musculoskeletal Pain in Golf Caddies-Johannesburg, South Africa

Golf is an important and growing industry in South Africa that currently fosters the creation of an informal job sector of which little is known about the health and safety risks. The purpose of the study is to investigate the prevalence and significance of musculoskeletal pain in male caddies compared to other golf course employees while holding contributing factors such as socioeconomic status, age, and education constant. Cross-sectional data were collected and analyzed from a convenience sample of 249 caddies and 74 non-caddies from six golf courses in Johannesburg, South Africa. Structural interviews were conducted to collect data on general demographics and musculoskeletal pain for two to three days at each golf course. On average, caddies were eight years older, had an income of 2880 rand less a month, and worked 4 h less a shift compared to non-caddies employed at the golf courses. Caddies were approximately 10% more likely to experience lower back and shoulder pain than non-caddies. Logistic regression models show a significantly increased adjusted odds ratio for musculoskeletal pain in caddies for neck (3.29, p = 0.015), back (2.39, p = 0.045), arm (2.95, p = 0.027), and leg (2.83, p = 0.019) compared to other golf course workers. The study findings indicate that caddying, as a growing informal occupation is at higher risk for musculoskeletal pain in caddies. Future policy should consider the safety of such a vulnerable population without limiting their ability to generate an income.

A case-control study of musculoskeletal impairment: association with socio-economic status, time use and quality of life in post-conflict Myanmar

Background

Musculoskeletal impairments (MSI) are a major global contributor to disability. Evidence suggests entrenched cyclical links between disability and poverty, although few data are available on the link of poverty with MSI specifically. More data are needed on the association of MSI with functioning, socio-economic status and quality of life, particularly in resource-poor settings where MSI is common.

Methods

We undertook a case-control study of the association between MSI and poverty, time use and quality of life in post-conflict Myanmar. Cases were recruited from two physical rehabilitation service-centres, prior to the receipt of any services. One age- (+/− 5 years of case’s age) and sex- matched control was recruited per case, from their home community. 108 cases and 104 controls were recruited between July – December 2015. Cases and controls underwent in-depth structured interviews and functional performance tests at multiple time points over a twelve-month period. The baseline characteristics of cases and controls are reported in this manuscript, using multivariate logistic regression analysis and various tests of association.

Results

89% of cases were male, 93% were lower limb amputees, and the vast majority had acquired MSI in adulthood. 69% were not working compared with 6% of controls (Odds Ratio 27.4, 95% Confidence Interval 10.6–70.7). Overall income, expenditure and assets were similar between cases and controls, with three-quarters of both living below the international LMIC poverty line. However, cases’ health expenditure was significantly higher than controls’ and associated with catastrophic health expenditure and an income gap for one fifth and two thirds of cases respectively. Quality of life scores were lower for cases than controls overall and in each sub-category of quality of life, and cases were far less likely to have participated in productive work the previous day than controls.

Conclusion

Adults with MSI in Myanmar who are not in receipt of rehabilitative services may be at increased risk of poverty and lower quality of life in relation to increased health needs and limited opportunities to participate in productive work. This study highlights the need for more comprehensive and appropriate support to persons with physical impairments in Myanmar.

Livelihood opportunities amongst adults with and without disabilities in Cameroon and India: A case control study

Proven links between disability and poverty suggest that development programmes and policies that are not disability-inclusive will leave persons with disabilities behind. Despite this, there is limited quantitative evidence on livelihood opportunities amongst adults with disabilities in Low and Middle Income Countries. This study adds to the limited evidence base, contributing data from one African and one Asian Setting. We undertook a population-based case–control study of adults (18+) with and without disabilities in North-West Cameroon and in Telangana State, India. We found that adults with disabilities were five times less likely to be working compared to age-sex matched controls in both settings. Amongst adults with disabilities, current age, marital status and disability type were key predictors of working. Inclusive programmes are therefore needed to provide adequate opportunities to participate in livelihood prospects for adults with disabilities in Cameroon and India, on an equal basis as others. These findings are of crucial importance at this stage of the Sustainable Development Agenda, to ensure that the mandate of inclusive development is achieved.

Musculoskeletal health conditions among older populations in urban slums in sub-Saharan Africa

BACKGROUND

Debate on the burden of musculoskeletal (MSK) conditions in lower and middle income countries is intensifying; yet, little knowledge so far exists on patterns and impacts of such conditions among general or older adult populations in sub-Saharan Africa (SSA). The objectives of this study are to examine the prevalence, potential predictors, and sequelae of MSK among older adults residing in two low resource informal urban settlements or "slums" in Nairobi Kenya.

METHODS

Data on older adults aged 60 years and over from two unrelated cross-sectional surveys on the older slum populations are used: a 2006/7 survey on the social, health, and overall well-being of older people (sample N = 831), and a 2016 survey on realities and impacts of long-term care and social protection for older adults (sample n = 1026). Uni and multivariate regressions on the 2006/7 data are employed to examine relationships of back pain and symptoms of arthritis with sex, age, wealth, unemployment, diagnoses of hypertension, and diabetes; and with indicators of subjective well-being and functional ability. Descriptive frequencies and chi-squared tests of association are used on 2016 data to identify the overall prevalence and locations of activity limiting MSK pain, and sex differences in these.

RESULTS

Prevalence of past month back pain and past 2 week symptoms of arthritis was 44% and 42.6%, respectively. Respective prevalence of past month activity limiting back pain and joint pain was 13.9% and 22.7%. A total of 42.6% of slum residents with a current health problem report MSK as the most severe problem. In multivariate regressions, female sex, unemployment, and diagnosis of hypertension are predictive of back pain and symptoms of arthritis. Both conditions are associated with raised odds of having lower quality of life, poorer life satisfaction, and depressive symptoms, and with mobility impairments and self-care difficulties.

CONCLUSIONS

MSK conditions are salient, and a likely key cause of impaired subjective well-being and functioning among older slum populations in SSA. Further research on determinants and consequences of such conditions in older slum populations is required to inform debate on responses to MSK as part of efforts to reorient SSA health systems to aging and to improve slum health.

Lives of persons with disabilities in Cameroon after CRPD: voices of persons with disabilities in the Buea Municipality in Cameroon

Introduction:

The Convention on the Rights of Persons with Disabilities (CRPD) has been touted as a major breakthrough towards achieving equal rights for persons with disabilities. The promulgation of the convention provided clear guidelines for signatory countries to revise their legislation as well as to formulate policies that will take into consideration the needs of persons with disabilities. As Cameroon is a signatory to the convention, it is expected that disability-friendly policies have been implemented to enhance the living conditions of persons with disabilities. This study examined, from the perspectives of participants, the life experiences of persons with disabilities in the Buea Municipality 7 years after Cameroon signed the CRPD.

Methods:

The study adopted a qualitative method, involving focus-group discussions with 36 participants from three disability groups: hearing impaired, visually impaired, and physically impaired.

Findings:

The study found that persons with disabilities in the Buea Municipality faced many challenges in their daily endeavors. These challenges are a result of a lack of inclusive policies, leading to their exclusion from social and economic activities such as education, employment, and healthcare.

Conclusion:

Although the study is limited in scope, the findings suggest that persons with disabilities in the Buea Municipality were yet to benefit from the CRPD. It is, therefore, suggested that the government of Cameroon should formulate inclusive policies to address the numerous challenges facing persons with disabilities in the Buea Municipality.

A time for action: Opportunities for preventing the growing burden and disability from musculoskeletal conditions in low- and middle-income countries

Musculoskeletal (MSK) conditions cause an enormous global burden, and this is dramatically increasing in developing countries, particularly due to rapidly ageing populations and increasing obesity. Many of the global non-communicable disease (NCD) initiatives need to expand beyond the traditional 'top four' NCD groups by incorporating MSK diseases. It is critical that MSK initiatives in developing countries integrate well with health systems, rather than being stand-alone. A better inclusion of MSK conditions will avoid doubling of efforts and wasting of resources, and will help to promote a more streamlined, cost-effective approach. Other key opportunities for action include the following: ensuring the principles of 'development effectiveness' are met; strengthening leadership and commitment; building the research, information and evidence base; and reducing the incidence and disability of MSK conditions through better prevention. Each of these elements is necessary to mitigate and reduce the growing burden from the MSKs.

The impact of disability on the lives of children; cross-sectional data including 8,900 children with disabilities and 898,834 children without disabilities across 30 countries

Background

Children with disabilities are widely believed to be less likely to attend school or access health care, and more vulnerable to poverty. There is currently little large-scale or internationally comparable evidence to support these claims. The aim of this study was to investigate the impact of disability on the lives of children sponsored by Plan International across 30 countries.

Methods and Findings

We conducted a cross-sectional survey including 907,734 children aged 0–17 participating in the Plan International Sponsorship Programme across 30 countries in 2012. Parents/guardians were interviewed using standardised questionnaires including information on: age, sex, health, education, poverty, and water and sanitation facilities. Disability was assessed through a single question and information was collected on type of impairment. The dataset included 8,900 children with reported disabilities across 30 countries. The prevalence of disability ranged from 0.4%–3.0% and was higher in boys than girls in 22 of the 30 countries assessed – generally in the range of 1.3–1.4 fold higher. Children with disabilities were much less likely to attend formal education in comparison to children without disabilities in each of the 30 countries, with age-sex adjusted odds ratios exceeding 10 for nearly half of the countries. This relationship varied by impairment type. Among those attending school, children with disabilities were at a lower level of schooling for their age compared to children without disabilities. Children with disabilities were more likely to report experiencing a serious illness in the last 12 months, except in Niger. There was no clear relationship between disability and poverty.

Conclusions

Children with disabilities are at risk of not fulfilling their educational potential and are more vulnerable to serious illness. This exclusion is likely to have a long-term deleterious impact on their lives unless services are adapted to promote their inclusion.

Is 'legal empowerment of the poor' relevant to people with disabilities in developing countries? An empirical and normative review

Background

Legal empowerment of the poor is highly relevant to public health as it aims to relieve income poverty, a main determinant of health. The Commission on Legal Empowerment of the Poor (CLEP) has proposed legal empowerment measures in the following four domains: access to justice and the rule of law, property, labor, and business rights. Despite being overrepresented among the poor, CLEP has not explicitly considered the situation of people with disabilities.

Objectives

To examine the empirical evidence for the relevance of the CLEP legal empowerment measures to people with disabilities in low- and lower middle-income countries, and to evaluate the extent to which the Convention on the Rights of Persons with Disabilities (CRPD) addresses those measures.

Methods

Critical literature review of empirical studies and a checklist assessment of the CRPD.

Results

Fourteen included articles confirm that people with disabilities experience problems in the domains of access to justice and the rule of law, labor rights, and business rights. No texts on property rights were found. Evidence for the effectiveness of the proposed measures is insufficient. Overall, the CRPD fully or partially supports two-thirds of the proposed measures (seven out of nine measures for access to justice and the rule of law, none of the five measures for property rights, all seven measures for labor rights, and six out of nine measures for business rights).

Conclusions

Although most of the domains of the CLEP legal empowerment measures are relevant to people with disabilities from both empirical and normative perspectives, it is uncertain whether the devised measures are of immediate relevance to them. Further research is warranted in this regard.

Childhood disability and socio-economic circumstances in low and middle income countries: systematic review

BACKGROUND

The majority of children with disability live in low and middle income (LAMI) countries. Although a number of important reviews of childhood disability in LAMI countries have been published, these have not, to our knowledge, addressed the association between childhood disability and the home socio-economic circumstances (SEC). The objective of this study is to establish the current state of knowledge on the SECs of children with disability and their households in LAMI countries through a systematic review and quality assessment of existing research.

METHODS

Electronic databases (MEDLINE; EMBASE; PUBMED; Web of Knowledge; PsycInfo; ASSIA; Virtual Health Library; POPLINE; Google scholar) were searched using terms specific to childhood disability and SECs in LAMI countries. Publications from organisations including the World Bank, UNICEF, International Monetary Fund were searched for. Primary studies and reviews from 1990 onwards were included. Studies were assessed for inclusion, categorisation and quality by 2 researchers.

RESULTS

24 primary studies and 13 reviews were identified. Evidence from the available literature on the association between childhood disability and SECs was inconsistent and inconclusive. Potential mechanisms by which poverty and low household SEC may be both a cause and consequence of disability are outlined in the reviews and the qualitative studies. The association of poor SECs with learning disability and behaviour problems was the most consistent finding and these studies had low/medium risk of bias. Where overall disability was the outcome of interest, findings were divergent and many studies had a high/medium risk of bias. Qualitative studies were methodologically weak.

CONCLUSIONS

This review indicates that, despite socially and biologically plausible mechanisms underlying the association of low household SEC with childhood disability in LAMI countries, the empirical evidence from quantitative studies is inconsistent and contradictory. There is evidence for a bidirectional association of low household SEC and disability and longitudinal data is needed to clarify the nature of this association.

Chronic haematogenous osteomyelitis in children: an unsolved problem

From a global point of view, chronic haematogenous osteomyelitis in children remains a major cause of musculoskeletal morbidity. We have reviewed the literature with the aim of estimating the scale of the problem and summarising the existing research, including that from our institution. We have highlighted areas where well-conducted research might improve our understanding of this condition and its treatment.

Vernal keratoconjunctivitis in school children in Rwanda and its association with socio-economic status: a population-based survey

Vernal keratoconjunctivitis (VKC) is an allergic eye disease and an important cause of hospital referral among children in Africa and Asia. Hospital-based studies have suggested a role for parasites in its pathogenesis. To determine the prevalence and risk factors for VKC in Central Africa, we conducted a nested population-based case control study in Rwanda, involving randomly selected primary schools from different environments (rural/urban) and climate. A prevalence of VKC of 4.0% (95% confidence interval 3.3-4.7%) was found among 3,041 children studied (participation rate 94.7%). The intestinal parasitic burden was not related to VKC. Besides hot dry climate (odds ratio [OR] = 1.5, P = 0.05) and male gender (OR = 1.7, P = 0.005), multivariate analysis identified higher economic status as a risk for VKC (OR = 1.4, P = 0.005). The effect on VKC of higher economic status appears not to act through differences in parasitic intestinal load.

Does recent contact with a health care provider make a difference in malaria knowledge?

Knowledge and practices with respect to malaria are aspects that need to be considered as part of effective malaria programs. We assessed and compared malaria practices and knowledge among those who had recently visited a health care provider and those who had not. A matched, population-based case-control study was conducted among 338 women between 15 and 45 years of age and caretakers of children ≤ 9 years of age in Nouna, Burkina Faso. Little difference was found in the reported responses between the cases and controls, which indicates that recent visits to health care providers may not have an effect on malaria risk or knowledge. Differences were noted in malaria practices, which could suggest that health care providers are consulted only after home treatments fail. Therefore, programs and policies targeted to health care providers aimed at improving the dissemination of information may be of some benefit.

A case-control study to assess the relationship between poverty and visual impairment from cataract in Kenya, the Philippines, and Bangladesh

BACKGROUND

The link between poverty and health is central to the Millennium Development Goals (MDGs). Poverty can be both a cause and consequence of poor health, but there are few epidemiological studies exploring this complex relationship. The aim of this study was to examine the association between visual impairment from cataract and poverty in adults in Kenya, Bangladesh, and the Philippines.

METHODS AND FINDINGS

A population-based case-control study was conducted in three countries during 2005-2006. Cases were persons aged 50 y or older and visually impaired due to cataract (visual acuity < 6/24 in the better eye). Controls were persons age- and sex-matched to the case participants with normal vision selected from the same cluster. Household expenditure was assessed through the collection of detailed consumption data, and asset ownership and self-rated wealth were also measured. In total, 596 cases and 535 controls were included in these analyses (Kenya 142 cases, 75 controls; Bangladesh 216 cases, 279 controls; Philippines 238 cases, 180 controls). Case participants were more likely to be in the lowest quartile of per capita expenditure (PCE) compared to controls in Kenya (odds ratio = 2.3, 95% confidence interval 0.9-5.5), Bangladesh (1.9, 1.1-3.2), and the Philippines (3.1, 1.7-5.7), and there was significant dose-response relationship across quartiles of PCE. These associations persisted after adjustment for self-rated health and social support indicators. A similar pattern was observed for the relationship between cataract visual impairment with asset ownership and self-rated wealth. There was no consistent pattern of association between PCE and level of visual impairment due to cataract, sex, or age among the three countries.

CONCLUSIONS

Our data show that people with visual impairment due to cataract were poorer than those with normal sight in all three low-income countries studied. The MDGs are committed to the eradication of extreme poverty and provision of health care to poor people, and this study highlights the need for increased provision of cataract surgery to poor people, as they are particularly vulnerable to visual impairment from cataract.