Barriers to the Implementation of the Health and Rehabilitation Articles of the United Nations Convention on the Rights of Persons with Disabilities in South Africa

Health Management Service Models for the Elderly with Visual Impairment: A Scoping Review

Background

The incidence of visual impairment(VI) in older people is gradually increasing. This review aimed to summarise the evidence on existing health management models and strategies for older adults with VI to improve health-related and vision-related quality of life (QoL) in older people.

Methods

Based on the framework of the scoping review methodology of Arksey and O'Malley (2005), a comprehensive literature search of relevant literature published between January 2010 and June 2022 in PubMed, CINAHL, EMBASE, Web of Science, Cochrane Library, CNKI, VIP, Wanfang database, Sinomed and the grey literature.

Results

Finally, 31 articles were included. The health management model had a multidisciplinary team low vision rehabilitation model, medical consortium two-way management model, low vision community comprehensive rehabilitation model, medical consortium-family contract service model, screening-referral-follow-up model, and three-level low vision care model. The health management strategy covers nine aspects, the combination of multi-element strategies is feasible, and network information technology has also shown positive results.

Conclusion

In the future, under the Internet and hierarchical management model, we should provide demand-based personalized support to rationalize and scientifically achieve hierarchical management and improve resource utilization efficiency and eye health outcomes.

Let the records speak: an exploration of rehabilitation services offered in primary healthcare, Johannesburg metropolitan district

BACKGROUND

Primary healthcare in South Africa aims to transform the national health system by emphasising community-based care and preventive strategies. However, rehabilitation services, particularly for individuals with disabilities and chronic non-communicable diseases, are often overlooked in primary healthcare. This study aimed to investigate the provision of primary healthcare rehabilitation services in the Johannesburg Metropolitan District by exploring client sociodemographics and variations in services provided by rehabilitation professionals.

METHODS

A retrospective review of clinic rehabilitation records from 2011 to 2020 was conducted at nine provincially funded community health centres (CHCs) offering rehabilitation services. Stratified sampling facilitated record selection based on rehabilitation service type and year. A specifically designed data extraction tool captured demographics, disabilities, rehabilitation received, and referral sources. Descriptive analysis used means, standard deviations, and frequencies.

RESULTS

The findings show a diverse client population with a wide age range, with a significant proportion falling into the < 5 years and 30-49 years age groups. Neuromusculoskeletal and movement-related disabilities were most prevalent, affecting approximately two-thirds of clients. Referral sources were often undocumented, and inconsistent discharge information with no record of patient follow up, highlighted the need for improved documentation practices. Clinic visits were the primary service delivery mode, followed by limited home visits and outreach services. Occupational therapy and physiotherapy were the most used services. Speech and language therapy services were underused, and some CHCs lacked audiology services. There were variations in the number of individual and group sessions provided by the different rehabilitation services, and there were age- and disability-specific differences in service use.

CONCLUSION

This study offers insights into rehabilitation service provision in the Johannesburg Metropolitan District and enhances our understanding of rehabilitation services in primary healthcare settings. It underscores the importance of a multidisciplinary rehabilitation team to address diverse rehabilitation needs, improving documentation and discharge practices, expanding service delivery models, and reducing disparities in service use. The findings inform strategies for optimising service delivery, workforce, resource allocation, and intersectoral collaboration to ultimately enhance the quality and accessibility of integrated rehabilitation services.

Impact on persons with disabilities and their families when they are contributors to society through volunteerism and employment

BACKGROUND

Despite various government initiatives, people with disabilities all over the world face some degree of hindrance when they try to contribute to society.

AIM

This project sought to give voice to and understand the perceptions and experiences of persons with disabilities in Singapore when contributing to society through volunteerism and employment and to explore solutions to help access and retain employment and volunteering.

METHOD AND PROCEDURE

This small qualitative study recruited three convenience samples of people with disabilities aged 18-49 years old who met criteria for daily activity over the previous 12 months. Participant recruitment was limited due to the Covid pandemic lockdown. Ten individuals had maintained open employment, six had worked as a volunteer and four were neither working nor volunteering. All 20 participants were briefed online on the use of the photovoice technique. Interviews were then conducted online, beginning with a 5-min demographic survey. Approximately hour long semi-structured interviews followed. Eleven participants used photovoice but nine who were working or volunteering did not as they were unable to take photos in their workplace. Several individuals were supported during the interview by a caregiver or staff member for example a job coach.

FINDINGS

Themes were identified within the four central areas of enquiry: (i) self-perceptions of being a beneficiary or contributor to society; (ii) the benefits to working and volunteering; (iii) enablers and barriers to working and volunteering and (iv) solutions to access and retain employment and volunteering. Several barriers to use of photovoice were encountered. The importance of inclusive and conducive environments was recognised along with the roles of all stakeholders across the ecosystem.

CONCLUSION

Employment and volunteering can significantly impact quality of life for persons with disabilities and their families and benefit the society. Collaboration among all stakeholders is required to better address solutions and improve desired employment and volunteer outcomes.

Hearing and Functioning in Everyday Life Questionnaire: Development and Validation of an ICF-Based Instrument

OBJECTIVES

Self-assessment instruments are commonly used in audiological rehabilitation. However, several studies highlight the lack of multidimensionality in existing outcome measures, with the consequence that they only partially capture aspects of functioning in everyday life for people living with hearing loss. This study aimed to develop and investigate the content validity of a self-assessment instrument based on the validated Brief International Classification of Functioning, Disability, and Health Core Set for Hearing Loss.

DESIGN

The design was a two-part instrument development study. The first part focused on the item-generation process of the instrument, named the Hearing and Functioning in Everyday Life Questionnaire (HFEQ) during an experts' workshop. The second part focused on international content validation of the instrument using group interviews. Strategic sampling was used and 30 adults with hearing loss from India, South Africa, and the United States participated in the group interviews.

RESULTS

The expert's workshop resulted in the first version of the HFEQ containing 30 items. The results from group interviews show that the content of the HFEQ was considered to be valid concerning its relevance, comprehensiveness, and comprehensibility. A majority (73%) of the HFEQ items were perceived by the participants as relevant and easy to comprehend. For the remaining 27% of the items, the content was perceived to be relevant in all countries, but some terms and expressions were reported to require rewording or clearer examples. These modifications will be made in the next step of the development process.

CONCLUSION

Content validation of the HFEQ demonstrates promising results, with participants perceiving the content as relevant and comprehensible. Further psychometric validation is required to investigate other psychometric properties, such as construct validity and reliability. The HFEQ has the potential to become a valuable new instrument for assessing everyday functioning in people with hearing loss in audiological rehabilitation and in research.

Public sector rehabilitation services for physical disabilities in tertiary care hospitals of Karachi, Pakistan: A qualitative study

BACKGROUND

Around the globe there are 2.4 billion people in need of rehabilitation. Disability and rehabilitation have not gained much importance in the public health arena, possibly due to limited research and awareness regarding the significance of rehabilitation. This study aimed to provide an in-depth understanding of the barriers and facilitators to the provision and utilization of rehabilitation services in public sector tertiary care hospitals of Karachi, Pakistan.

METHODOLOGY

This qualitative exploratory study was conducted from August to September 2015 in two tertiary care hospitals of Karachi. The criterion for hospital selection included the availability of functional rehabilitation services. Twenty-four key informant interviews were conducted with health professionals, including doctors, physiotherapists, occupational therapists, prosthetists, orthotists, as well as patients and caregivers. Qualitative content analysis was performed using a consensual qualitative research approach. Responses from key informant interviews were coded into free nodes and then categorized into themes.

RESULTS

Two themes emerged from the data: constraints to the provision of rehabilitation services, and barriers to the utilization of rehabilitation services. Basic infrastructure was available at both study sites; however, a lack of structured guidelines for referring patients to these services, a lack of information-sharing and guidance to the patients, and a limited supply of equipment (treatment modalities) hampered the provision of services. The barriers to rehabilitation services included cost pertaining to transport, environmental barriers, lack of support from the employer, and strain on and lack of support from caregivers.

CONCLUSION

Rehabilitation services require attention and investment in research and allocation of funds to strengthen the service delivery system. Hospitals, alongside the department of health, need to develop a strategic plan to set future directions and standards of available rehabilitation services.

Prioritizing rehabilitation in low- and middle-income country national health systems: a qualitative thematic synthesis and development of a policy framework

BACKGROUND

There is a large and growing unmet need for rehabilitation - a diverse category of services that aim to improve functioning across the life course - particularly in low- and middle-income countries. Yet despite urgent calls to increase political commitment, many low- and middle-income country governments have dedicated little attention to expanding rehabilitation services. Existing policy scholarship explains how and why health issues reach the policy agenda and offers applicable evidence to advance access to physical, medical, psychosocial, and other types of rehabilitation services. Drawing from this scholarship and empirical data on rehabilitation, this paper proposes a policy framework to understand national-level prioritization of rehabilitation in low- and middle-income countries.

METHODS

We conducted key informant interviews with rehabilitation stakeholders in 47 countries, complemented by a purposeful review of peer-reviewed and gray literature to achieve thematic saturation. We analyzed the data abductively using a thematic synthesis methodology. Rehabilitation-specific findings were triangulated with policy theory and empirical case studies on the prioritization of other health issues to develop the framework.

RESULTS

The novel policy framework includes three components which shape the prioritization of rehabilitation on low- and middle-income countries' national government's health agendas. First, rehabilitation lacks a consistent problem definition, undermining the development of consensus-driven solutions which could advance the issue on policy agendas. Second, governance arrangements are fragmented within and across government ministries, between the government and its citizens, and across national and transnational actors engaged in rehabilitation service provision. Third, national legacies - particularly from civil conflict - and weaknesses in the existing health system influences both rehabilitation needs and implementation feasibility.

CONCLUSIONS

This framework can support stakeholders in identifying the key components impeding prioritization for rehabilitation across different national contexts. This is a crucial step for ultimately better advancing the issue on national policy agendas and improving equity in access to rehabilitation services.

A review of the framework and strategy for disability and rehabilitation services in South Africa

Background

Rehabilitation is imperative for the successful integration of persons with disabilities into their social environments. The Framework and strategy for disability and rehabilitation services (FSDR) in South Africa, 2015-2020.was developed to strengthen access to rehabilitation services and ensure the inclusion of persons with disabilities in all aspects of community life. Despite the FSDR being commissioned, access to rehabilitation is a challenge for persons with disabilities and further compounded in rural communities.

Objective

The study aimed to describe the barriers and facilitators that influenced the process of development, implementation and monitoring of the FSDR.

Method

This qualitative study employed a single case study design. Data was collected through document analysis and in-depth interviews utilising the Walt & Gilson policy analysis framework that outlines the context, content, actors and process of policy development and implementation. In-depth interviews were conducted with twelve key informants (N=12) who were selected purposively for the study. Data obtained from the in-depth interviews were analysed using inductive thematic analysis.

Results

We found many factors that influenced the implementation of the framework. Actor dynamics, insufficient resources, the rushed process, poor record-keeping, inappropriate leadership, negative attitudes of staff members and the insufficient monitoring impeded the successful implementation of the framework. While positive attitude, mentorship and support amongst the task team facilitated the implementation process, albeit with challenges.

Conclusion

There is a need to address implementation gaps so that the FSDR is responsive to the current rehabilitation needs of persons with disabilities in South Africa.

Contribution

This study may inform future disability policy, and can be used as a tool to advocate for the rights for persons with disabilities.

Towards universal health coverage for people with stroke in South Africa: a scoping review

OBJECTIVES

To explore the opportunities and challenges within the health system to facilitate the achievement of universal health coverage (UHC) for people with stroke (PWS) in South Africa (SA).

SETTING

SA.

DESIGN

Scoping review.

SEARCH METHODS

We conducted a scoping review of opportunities and challenges to achieve UHC for PWS in SA. Global and Africa-specific databases and grey literature were searched in July 2020. We included studies of all designs that described the healthcare system for PWS. Two frameworks, the Health Systems Dynamics Framework and WHO Framework, were used to map data on governance and regulation, resources, service delivery, context, reorientation of care and community engagement. A narrative approach was used to synthesise results.

RESULTS

Fifty-nine articles were included in the review. Over half (n=31, 52.5%) were conducted in Western Cape province and most (n=41, 69.4%) were conducted in urban areas. Studies evaluated a diverse range of health system categories and various outcomes. The most common reported component was service delivery (n=46, 77.9%), and only four studies (6.7%) evaluated governance and regulation. Service delivery factors for stroke care were frequently reported as poor and compounded by context-related limiting factors. Governance and regulations for stroke care in terms of government support, investment in policy, treatment guidelines, resource distribution and commitment to evidence-based solutions were limited. Promising supporting factors included adequately equipped and staffed urban tertiary facilities, the emergence of Stroke units, prompt assessment by health professionals, positive staff attitudes and care, two clinical care guidelines and educational and information resources being available.

CONCLUSION

This review fills a gap in the literature by providing the range of opportunities and challenges to achieve health for all PWS in SA. It highlights some health system areas that show encouraging trends to improve service delivery including comprehensiveness, quality and perceptions of care.

Cross-national study of communal attitudes toward individuals with intellectual disabilities in sub-Saharan Africa: Cameroon vs. Ghana

BACKGROUND

An intellectual disability (ID) is characterized by a deficit in the functional, cognitive, and adaptive skills required for independent living. Due to the low cognitive capabilities of individuals with IDs, they have become victims of marginalization, exclusion, and denial of their fundamental rights to basic necessities in societies around the world. While efforts are being made to improve service provision to and acceptance of individuals with disabilities, the extent of communal acceptance and recognition of these individuals as equal members of society remains underexplored in sub-Saharan African countries such as Cameroon and Ghana.

OBJECTIVE

As attitudes toward individuals with IDs are pivotal in shaping national policies, this cross-national study examined communal attitudes toward persons with IDs in Cameroon and Ghana.

METHOD

The Community Living Attitude Scale for Intellectual Disabilities (CLAS-ID) was used to collect data from a total of 741 university students in the two countries. The validity of the scale was assessed using confirmatory factor analysis and principal component analysis. The association between the background variables and attitudes was examined using t-tests, analysis of variance, linear regression, and two-way factor analysis.

RESULTS

The results showed the validity of the CLAS-ID as a valid tool for measuring communal attitudes toward individuals with IDs in sub-Saharan Africa. The participants appeared ambivalent about attitude towards individuals with ID and other findings showed no association between attitudes and variables such as gender, relation, and contact with individuals with IDs.

CONCLUSION

We discuss the need for innovative approaches aimed at changing attitudes toward individuals with IDs in sub-Saharan Africa as well as other study implications.

A chasm: Consequences of poor collaboration between health and education in paediatric cerebral palsy care in Johannesburg

BACKGROUND

Nearly 20 years since the establishment of the National Rehabilitation Policy, strides have been made within the health and education sectors to improve accessibility to rehabilitation services as well as the quality of life of children with cerebral palsy (CP). Shortfalls, however, still exist in implementing the policy. An in-depth study into the implementation of policy would be beneficial in identifying and understanding the shortfalls of the rehabilitation process.

OBJECTIVES

To investigate the perceptions of Speech-Language Therapists (SLTs) working in the Gauteng Department of Health (GDH) and Gauteng Department of Education (GDE), in Johannesburg Region A, about systemic strengths and weaknesses surrounding the service delivery for children with CP, from birth to 6 years.

METHOD

A qualitative study was conducted. Thirty-one (31) SLTs working in public hospitals, clinics and schools for Learners with Special Educational Needs participated in eight focus group interviews. Interviews were audio-recorded for transcription and subsequent thematic analysis.

RESULTS

The participants reported a lack of resources and knowledge that contributed to a perceived chasm between the GDH and GDE, resulting in fragmented and uncoordinated service delivery for children with CP leaving the health system and entering the education system.

CONCLUSION

The results suggest that a cohesive plan should be formulated to bridge the perceived chasm between GDH and GDE in the referral process of children with CP from the health setting, into the school environment. This may facilitate communication, collaboration, education, as well as resource-sharing between the departments. Rehabilitation professionals should actively participate in such planning processes.

Growing physical rehabilitation needs in resource-poor world regions: secondary, cross-regional analysis with data from the global burden of disease 2017

PURPOSE

This paper aims to analyze the levels and trajectories of physical rehabilitation needs across five resource-poor world regions, against global and key country-specific benchmarks.

MATERIALS AND METHODS

This comparative, secondary cross-region analysis uses data from the Global Burden of Diseases study 2017 [1990-2017], specifically varied metrics of the Years Lived with Disability (YLD) measure from the health conditions likely benefiting from physical rehabilitation.

RESULTS

All the resource-poor world regions had significant increases (p < 0.01) in the absolute, relative, and percentage of physical rehabilitation needs [1990-2017]. Nonetheless, The Asia-Pacific region stood out with the greatest YLD Rates (i.e., per population size) in 2017, the greatest growth in YLD Rates since 1990 (38%), and an exponential growth in the rehabilitation-sensitive YLD Rates. The Asia-Pacific region also had the greatest portion of their YLDs coming from rehabilitation-sensitive conditions (72% in 2017), closely followed by the Latin America & Caribbean (67%). Nonetheless, in South Asia and Sub-Saharan Africa, we observed the greatest percent increases in the portion of physical rehabilitation needs among all YLDs, out of lower initial values.

CONCLUSIONS

An overall growth but differential patterns were observed in the evolution of physical rehabilitation needs across the resource-poor world regions.IMPLICATIONS FOR REHABILITATIONAsia-Pacific and Latin America & Caribbean regions had over than two-thirds of their non-fatal health loss arising from conditions sensitive to physical rehabilitation, and important growths in rehabilitation need indicators have been observed also for South Asia and Sub-Saharan Africa.The scale-up and strengthening of rehabilitation services and resources should be informed by needs-based data.The needs-based data from this study can inform trans-national developments and the planning of rehabilitation resources, inclusively at the world-region level.

A qualitative exploration of barriers in accessing community pharmacy services for persons with disability in Addis Ababa, Ethiopia: a cross sectional phenomenological study

BACKGROUND

It was estimated that over a billion people have a disability and around 110 to 190 million experienced significant difficulties in functioning. Similarly, there were over 5 million and 32,630 individuals with disability in Ethiopia and Addis Ababa, the capital city of Ethiopia, respectively. Health care is a human right, yet access barriers to healthcare remain one of the major challenges among people with disabilities. Community pharmacists are often the health system point of entry for most patients. Therefore, the aim of this study was to explore the barriers to community pharmacy service for individuals with physical, visual and hearing disability in Addis Ababa, Ethiopia.

METHODS

A cross sectional phenomenological qualitative study design was employed to explore the barriers to community pharmacy service for individuals with Physical, Visual and Hearing disability. All members from Ethiopian National Association of the Blind (ENAB), Ethiopian National Association of the Deaf (ENAD) and Ethiopian National Association of persons with Physical Disability (ENAPPD) and all community pharmacy professionals in Addis Ababa were the study populations in this study. The analysis was made using content analysis where ideas were classified into themes manually.

RESULT

All informants with disability pointed out that community pharmacy services were not accessible to them. The study found transportation, physical layout, communication and medication price were the main barriers to obtain community pharmacy services among individuals with visual, physical and hearing disabilities. Respondents also witnessed that pharmacists provided proper counseling and were also cooperative and willing to help them.

CONCLUSIONS

This study indicated that individuals with disability experienced different access barriers to community pharmacy services. Further studies are recommended to identify other community pharmacy disparities and access barriers to pharmacy services and propose possible solutions.

Determinants of Travel Participation and Experiences of Wheelchair Users Traveling to the Bodrum Region: A Qualitative Study

Although the number of people with disabilities and types of disability increases day by day, a sufficient point has not been reached regarding accessible tourism. The participation rate of people with disabilities (PWDS) in tourism activities is low, and there is a big gap in the travel and accommodation sector in this regard. Studies of previous scholars have concluded that the accessible tourism market is a significant and profitable area, but determinants of participation to travel and process of travel, such as wheelchair user expectations, are consistently ignored by the tourism industry. The main purpose of this study is to determine the determinants of travel by examining the motivations, expectations, processes and experiences of PWDS using wheelchairs to participate in tourism. Research was performed in Turkey’s Bodrum district; 25 wheelchair users were included in the study. The keywords that emerged in the theoretical framework in light of the answers given to 39 open-ended questions online were coded in the Nvivo program. The results showed that wheelchair users intended to go on vacation but were less motivated to participate due to the lack of travel conditions. Wheelchair travelers argued that a companion was required for an enjoyable holiday that could meet their needs. In addition, the results revealed that the types of wheelchairs used by disabled passengers differ. The disabled stated that the wheelchairs they use in daily life are not suitable for use on the beach, sand or water. Despite the economic, social and technological change opportunities, basic tourism service expectations of PWDS are not met. This research project is a comprehensive study that makes determinations in terms of examining the social status of disabled people in terms of social sciences, examining the place and importance of disabled tourists in the market and eliminating the deficiencies of facilities serving in tourism.

A Persons-Centered Approach for Prevention of COVID-19 Disease and Its Impacts in Persons With Disabilities

The World Health Organization (WHO) considers COVID-19 a great threat to humanity and, thus, declared the COVID-19 outbreak a pandemic on March 11, 2020. To limit its transmission, governments announced lockdowns in their respective nations, and recommended control measures, including behavior change. Persons with disabilities (PwDs) are among the population that may be at a higher risk of becoming infected and may suffer serious illness due to COVID-19. Additionally, lockdowns pose immense challenges and have tremendous impacts on PwDs in terms of receiving their daily support. To mitigate these challenges, their impact, and to reduce the risk of infection, it is important to design strategies that can improve the overall outcome for PwDs. This study therefore intends to provide a uniform strategy or guideline using the person-centered approach principles which is perhaps the most feasible and implementable approach to circumvent the challenges faced by PwDs during emergency lockdowns. Two case studies are used as examples. This pandemic also provides an opportunity for health care planners and policymakers in the health sector to implement reforms to ensure disability inclusiveness in potential future emergency lockdowns.

Convention on the rights of persons with disabilities: Qualitative exploration of barriers to the implementation of articles 25 (health) and 26 (rehabilitation) in Iran

Background: The International Convention on the Rights of Persons with Disabilities (CRPD) is the most important International Document for recognizing the rights of persons with disabilities, including the right to health and rehabilitation. Islamic Republic Iran acceded to the Convention in 2008, but still has a long way to go to achieve its desired status and in line with the objectives of the convention. This study aimed to identify the barriers to the implementation of articles 25 and 26 of the CRPD in Iran. Methods: This study was performed using conventional content analysis. Twenty-one individuals were recruited by purposive sampling with maximum variation and were continued until saturation. Data were gathered through in-depth, semi-structured interviews from June 2018 to May 2019. MAXQDA version 10 was used for analyzing data. Results: The resulting data analysis yielded 860 initial or open codes. The concepts were categorized into 27 subcategories and 7 categories. Main categories were included: "Structure inefficiency", "lack of comprehensive rehabilitation program", "inadequate awareness", "neglected economy of people with disabilities", "weak access to services", "cultural challenges" and "disregard for new technologies". Conclusion: The findings showed that the executive structures in the country have a lot of problems with health and rehabilitation programs for people with disabilities. It seems understanding the barriers to implementation of articles 25 and 26 of the international CRPD empowers officials in the field and improve services by providing a better view of the disabled. Nevertheless, it is recommended for policymakers to consider rehabilitation as a main element of the health system.

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.

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Disability is associated with high depression and low self-esteem in South Africa.

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Stigma partially mediates links between disability, depression and self-esteem.

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Unemployment exacerbates depression and low self-esteem.

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Education increases self-esteem.

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Anti-stigma policies are needed to achieve Sustainable Development Goals for all.

Barriers to accessing primary healthcare services for people with disabilities in low and middle-income countries, a Meta-synthesis of qualitative studies

METHODS

Six electronic databases were searched for relevant studies from 2000 to 2019. Forty-one eligible studies were identified.

RESULTS

Findings suggest that the people with disabilities' choice to seek healthcare services or not, as well as the quality of intervention provided by primary healthcare providers, are influenced by three types of barriers: cultural beliefs or attitudinal barriers, informational barriers, and practical or logistical barriers.

CONCLUSION

In order to achieve full health coverage at acceptable quality for people with disabilities, it is necessary not only to consider the different barriers, but also their combined effect on people with disabilities and their households. It is only then that more nuanced and effective interventions to improve access to primary healthcare, systematically addressing barriers, can be designed and implemented.IMPLICATIONS FOR REHABILITATIONPeople with disabilities in both high income and low- and middle-income country settings are more likely to experience poorer general health than people without disabilities.Barriers to accessing primary healthcare services for people with disabilities result from a complex and dynamic interacting system between attitudinal and belief system barriers, informational barriers, and practical and logistical barriers.Given primary healthcare is often the initial point of contact for referral to specialty care and rehabilitation services, it is crucial for people with disabilities to access primary healthcare services in order to get appropriate referrals for such services, specifically rehabilitation as appropriate.To achieve full health coverage at acceptable quality for people with disabilities, starting with primary healthcare, it is necessary for healthcare stakeholders, including rehabilitation professionals, to consider the combined and cumulative effects of the various barriers to healthcare on people with disabilities and their families and develop an understanding of how healthcare decisions are made by people with disabilities at the personal and the household level.

Physical Rehabilitation Needs in the BRICS Nations from 1990 to 2017: Cross-National Analyses Using Data from the Global Burden of Disease Study

Background: This study analyzes the current and evolving physical rehabilitation needs of BRICS nations (Brazil, Russian Federation, India, China, South Africa), a coalition of large emergent economies increasingly important for global health. Methods: Secondary, cross-national analyses of data on Years Lived with Disability (YLDs) were extracted from the Global Burden of Disease Study 2017. Total physical rehabilitation needs, and those stratified per major condition groups are analyzed for the year 2017 (current needs), and for every year since 1990 (evolution over time). ANOVAs are used to detect significant yearly changes. Results: Total physical rehabilitation needs have increased significantly from 1990 to 2017 in each of the BRICS nations, in every metric analyzed (YLD Counts, YLDs per 100,000 people, and percentage of YLDs relevant to physical rehabilitation; all p < 0.01). Musculoskeletal & pain conditions were leading cause of physical rehabilitation needs across the BRICS nations but to varying degrees: from 36% in South Africa to 60% in Brazil. Country-specific trends include: 25% of South African needs were from HIV-related conditions (no other BRICS nation had more than 1%); India had both absolute and relative growths of pediatric rehabilitation needs (p < 0.01); China had an exponential growth in the per-capita needs from neurological and neoplastic conditions (p < 0.01; r2 = 0.97); Brazil had a both absolute and relative growth of needs coming from musculoskeletal & pain conditions (p < 0.01); and the Russian Federation had the highest neurological rehabilitation needs per capita in 2017 (over than three times those of India, South Africa or Brazil). Conclusions: total physical rehabilitation needs have been increasing in each of the BRICS nations, both in absolute and relative values. Apart from the common growing trend, each of the BRICS nations had own patterns for the amount, typology, and evolution of their physical rehabilitation needs, which must be taken into account while planning for health and physical rehabilitation programs, policies and resources.

Income security during periods of ill health: a scoping review of policies, practice and coverage in low-income and middle-income countries

The COVID-19 pandemic is a reminder that insufficient income security in periods of ill health leads to economic hardship for individuals and hampers disease control efforts as people struggle to stay home when sick or advised to observe quarantine. Evidence on income security during periods of ill health is growing but has not previously been reviewed as a full body of work concerning low-income and middle-income countries (LMICs). We performed a scoping review to map the range, features, coverage, protective effects and equity of policies that aim to provide income security for adults whose ill health prevents them from participating in gainful work. A total of 134 studies were included, providing data from 95% of LMICs. However, data across the majority of these countries were severely limited. Collectively the included studies demonstrate that coverage of contributory income-security schemes is low, especially for informal and low-income workers. Meanwhile, non-contributory schemes targeting low-income groups are often not explicitly designed to provide income support in periods of ill health, they can be difficult to access and rarely provide sufficient income support to cover the needs of eligible recipients. While identifying an urgent need for more research on illness-related income security in LMICs, this review concludes that scaling up and diversifying the range of income security interventions is crucial for improving coverage and equity. To achieve these outcomes, illness-related income protection must receive greater recognition in health policy and health financing circles, expanding our understanding of financial hardship beyond direct medical costs.

Experiences accessing and using rehabilitation services for people with physical disabilities in Sierra Leone

Purpose: To explore the experiences of persons with physical disabilities accessing and using rehabilitation services in Sierra Leone.Materials and methods: Interviews of 38 individuals with differing physical disabilities in three locations across Sierra Leone. An inductive approach was applied, and qualitative content analysis used.Results: Participants faced several barriers to accessing and using rehabilitation services. Six themes emerged: The initial and ongoing need for rehabilitation throughout life; challenges with the cost of rehabilitation and transportation to reach rehabilitation services; varied experiences with rehabilitation staff; coming to terms with disability and encountering stigma; the struggles without and opportunities with rehabilitation services; and limited knowledge and availability of rehabilitation services.Conclusions: There is a continued need to address the barriers associated with the affordability of rehabilitation through the financing of rehabilitation and transportation and exploring low-cost care delivery models. Rehabilitation services, assistive devices, and materials need to be available in existing rehabilitation centres. A national priority list is recommended to improve the availability and coordination of rehabilitation services. Improved knowledge about disability and rehabilitation services in the wider community is needed. Addressing discriminatory health beliefs and the stigma affecting people with disabilities through community interventions and health promotion is recommended.Implications for RehabilitationFinancing for rehabilitation, transportation to services and low-cost delivery models of care areneeded to reduce financial barriers and increase affordability of access and use.Community interventions and health promotion can provide information about the utility and availability of rehabilitation services, while addressing health beliefs and stigma towards persons with disabilities.The availability of both rehabilitation services and information, that is relevant and accessible is required to facilitate improved access and use of rehabilitation services.

Toward an optimization of rehabilitation services for persons with spinal cord injury in Mongolia: the perspective of medical doctors

PURPOSE

To explore medical doctors' views on what are barriers in providing rehabilitation services for persons with SCI in Mongolia.

METHODS

A qualitative study with semi-structured interviews was conducted with 12 medical doctors. Participants were purposely sampled. The World Health Organization (WHO)'s report International Perspectives on Spinal Cord Injury was chosen as a guide to structure the interviews. The study used inductive thematic analysis.

RESULTS

Five barriers in the provision of rehabilitation services were identified: low awareness and limited knowledge regarding SCI and rehabilitation issues, inadequate rehabilitation policies, deficiencies in infrastructure, deficiencies in equipment and medication, and a shortage of well-prepared rehabilitation workforce.

CONCLUSIONS

Based on WHO recommendations "Rehabilitation in health systems", this study provides suggestions on how to strengthen rehabilitation services in Mongolia to better respond to the needs of the SCI population. Our findings highlight that a core issue is the lack of awareness among policymakers regarding rehabilitation and its benefits at the micro, meso and macro levels of the health system. Actions are needed at the level of health policies to ensure, for instance, adequate financing and access to the services. Also, synergies between the Ministries of Education and Health can improve the training of the workforce.Implications for rehabilitationEvidence that rehabilitation services contribute to improving health outcomes and cost-effectiveness could raise awareness among Mongolian policymakers and inform their decisions on funding schemes.Health policies in Mongolia should be reformed to remove barriers in the provision of rehabilitation services for persons with complex and chronic health conditions.Rehabilitation services need to be included into the Mongolian health insurance scheme in order to improve the quality and accessibility of rehabilitation services.Synergies between the Ministry of Education and the Ministry of Health in Mongolia are needed to develop training standards for rehabilitation professionals.

Prioritizing barriers and solutions to improve employment for persons with developmental disabilities

Purpose: Persons with a developmental disability have the lowest rate of labour force participation relative to other disabilities. The widening gap between the labour force participation of persons with versus without disability has been an enduring concern for many governments across the globe, which has led to policy initiatives such as labour market activation programs, welfare reforms, and equality laws. Despite these policies, persistently poor labour force participation rates for persons with developmental disabilities suggest that this population experiences pervasive barriers to participating in the labour force.Materials and methods: In this study, a two-phase qualitative research design was used to systematically identify, explore and prioritize barriers to employment for persons with developmental disabilities, potential policy solutions and criteria for evaluating future policy initiatives. Incorporating diverse stakeholder perspectives, a Nominal Group Technique and a modified Delphi technique were used to collect and analyze data.Results: Findings indicate that barriers to employment for persons with developmental disabilities are multi-factorial and policy solutions to address these barriers require stakeholder engagement and collaboration from multiple sectors.Conclusions: Individual, environmental and societal factors all impact employment outcomes for persons with developmental disabilities. Policy and decision makers need to address barriers to employment for persons with developmental disabilities more holistically by designing policies considering employers and the workplace, persons with developmental disabilities and the broader society. Findings call for cross-sectoral collaboration using a Whole of Government approach.Implications for RehabilitationPersons with a developmental disability face lower levels of labour force participation than any other disability group.Individual, environmental and societal factors all impact employment outcomes for persons with developmental disabilities.Decision and policy makers need to address barriers to employment for persons with developmental disabilities holistically through policies guiding employers and broader societal behaviour in addition to those aimed at the individuals (such as skill development or training).Due to multi-factorial nature of barriers to employment for persons with developmental disabilities, policy solutions are wide-ranging and fall under the responsibility of multiple sectors for implementation. This calls for cross-sectoral collaboration using a "Whole of Government" approach, with shared goals and integrated responses.

Using concept mapping to develop a human rights based indicator framework to assess country efforts to strengthen rehabilitation provision and policy: the Rehabilitation System Diagnosis and Dialogue framework (RESYST)

BACKGROUND

Rehabilitation is crucial for the realization of the right to health and a proper concern of global health. Yet, reliable information to guide rehabilitation service planning is unavailable in many countries in part due to the lack of appropriate indicators. To ensure universal health coverage and meet the central imperative of "leaving no one behind" countries must be able to assess key aspects of rehabilitation policy and provision and monitor how they have discharged their human rights responsibilities towards those most disadvantaged, including people with disability. This article describes the process of developing an expert guided indicator framework to assess governments' efforts and progress in strengthening rehabilitation in line with the Convention on the Rights of Persons with Disabilities.

METHODS

A systems methodology - concept mapping - was used to capture, aggregate and confirm the knowledge of diverse stakeholders on measures thought to be useful for monitoring the implementation of the Convention with respect to health related rehabilitation. Fifty-six individuals generated a list of 107 indicators through online brainstorming which were subsequently sorted by 37 experts from the original panel into non overlapping categories. Forty-one participants rated the indicators for importance and feasibility. Multivariate statistical techniques where used to explore patterns and themes in the data and create the indicators' organizing framework which was verified and interpreted by a select number of participants.

RESULTS

A concept map of 11 clusters of indicators emerged from the analysis grouped into three broader themes: Governance and Leadership (3 clusters); Service Delivery, Financing and Oversight (6 clusters); and Human Resources (2 clusters). The indicator framework was comprehensive and well aligned with the Convention. On average, there was a moderately positive correlation between importance and feasibility of the indicators (r = .58) with experts prioritizing the indicators contained in the clusters of the Governance and Leadership domain. Two of the most important indicators arose from the Service Delivery, Financing and Oversight domain and reflect the need to monitor unmet needs and barriers in access to rehabilitation. In total, 59 indicators achieved above average score for importance and comprised the two-tiered priority set of indicators.

CONCLUSION

Concept mapping was successful in generating a shared model that enables a system's view of the most critical legal, policy and programmatic factors that must be addressed when assessing country efforts to reform, upscale and improve rehabilitation services. The Rehabilitation Systems Diagnosis and Dialogue framework provides a data driven basis for the development of standardized data collection tools to facilitate comparative analysis of rehabilitation systems. Despite agreement on the importance and feasibility of 59 indicators, further research is needed to appraise the applicability and utility of the indicators and secure a realistic assessment of rehabilitation systems.

Assistive technology policy: a position paper from the first global research, innovation, and education on assistive technology (GREAT) summit

Increased awareness, interest and use of assistive technology (AT) presents substantial opportunities for many citizens to become, or continue being, meaningful participants in society. However, there is a significant shortfall between the need for and provision of AT, and this is patterned by a range of social, demographic and structural factors. To seize the opportunity that assistive technology offers, regional, national and sub-national assistive technology policies are urgently required. This paper was developed for and through discussion at the Global Research, Innovation and Education on Assistive Technology (GREAT) Summit; organized under the auspices of the World Health Organization's Global Collaboration on Assistive Technology (GATE) program. It outlines some of the key principles that AT polices should address and recognizes that AT policy should be tailored to the realities of the contexts and resources available. AT policy should be developed as a part of the evolution of related policy across a number of different sectors and should have clear and direct links to AT as mediators and moderators for achieving the Sustainable Development Goals. The consultation process, development and implementation of policy should be fully inclusive of AT users, and their representative organizations, be across the lifespan, and imbued with a strong systems-thinking ethos. Six barriers are identified which funnel and diminish access to AT and are addressed systematically within this paper. We illustrate an example of good practice through a case study of AT services in Norway, and we note the challenges experienced in less well-resourced settings. A number of economic factors relating to AT and economic arguments for promoting AT use are also discussed. To address policy-development the importance of active citizenship and advocacy, the need to find mechanisms to scale up good community practices to a higher level, and the importance of political engagement for the policy process, are highlighted. Policy should be evidence-informed and allowed for evidence-making; however, it is important to account for other factors within the given context in order for policy to be practical, authentic and actionable. Implications for Rehabilitation The development of policy in the area of asssitive technology is important to provide an overarching vision and outline resourcing priorities. This paper identifies some of the key themes that should be addressed when developing or revising assistive technology policy. Each country should establish a National Assistive Technology policy and develop a theory of change for its implementation.