Impacts of the COVID-19 pandemic on access to healthcare among people with disabilities: evidence from six low- and middle-income countries.

BACKGROUND: The pandemic has placed considerable strain on health systems, especially in low- and middle-income countries (LMICs), leading to reductions in the availability of routine health services. Emerging evidence suggests that people with disabilities have encountered marked challenges in accessing healthcare services and supports in the context of the pandemic. Further research is needed to explore specific barriers to accessing healthcare during the pandemic, and any strategies that promoted continued access to health services in LMICs where the vast majority of people with disabilities live. METHODS: Qualitative in-depth interviews were conducted with persons with disabilities in Ghana, Zimbabwe, Viet Nam, Türkiye (Syrian refugees), Bangladesh, and India as part of a larger project exploring the experiences of people with disabilities during the COVID-19 pandemic and their inclusion in government response activities. Data were analysed using thematic analysis. RESULTS: This research found that people with disabilities in six countries - representing a diverse geographic spread, with different health systems and COVID-19 responses - all experienced additional difficulties accessing healthcare during the pandemic. Key barriers to accessing healthcare during the pandemic included changes in availability of services due to systems restructuring, difficulty affording care due to the economic impacts of the pandemic, fear of contracting coronavirus, and a lack of human support to enable care-seeking. CONCLUSION: These barriers ultimately led to decreased utilisation of services which, in turn, negatively impacted their health and wellbeing. However, we also found that certain factors, including active and engaged Organisations of Persons with Disabilities (OPDs) and Non-Governmental Organizations (NGOs) played a role in reducing some of the impact of pandemic-related healthcare access barriers.

'Do they ever think about people like us?': The experiences of people with learning disabilities in England and Scotland during the COVID-19 pandemic.

People with learning disabilities in England and Scotland have experienced an increased risk of illness and death during the COVID-19 pandemic. Drawing on data of a longitudinal qualitative study with 71 disabled people and 31 disability organisations, this article examines the experiences of 24 people with learning disabilities in England and Scotland during the pandemic, reflecting on what rendered them vulnerable and placed them at risk. Qualitative interviews were conducted with participants and key informants at two timepoints; June-August 2020 and February-April 2021. Findings emerged across four key themes: failure to plan for the needs of people with learning disabilities; the suspension and removal of social care; the impact of the pandemic on people's everyday routines; and lack of vaccine prioritisation. The inequalities experienced by people with learning disabilities in this study are not particular to the pandemic. We explore the findings in the context of theoretical frameworks of vulnerability, including Fineman's conceptualisation of a 'vulnerability paradigm'. We conclude that the structured marginalisation of people with disabilities, entrenched by government action and inaction, have created and exacerbated their vulnerability. Structures, policies and action must change.

Are Nepal's water, sanitation and hygiene and menstrual hygiene policies and supporting documents inclusive of disability? A policy analysis.

PURPOSE: This study assesses the inclusion of disability in Nepal's policy and guidance relevant to water, sanitation and hygiene (WASH), and menstrual hygiene management (MHM) in comparison to gender. We investigated both policy formulation and implementation, using the Kavrepalanchok district as a case study. MATERIALS AND METHODS: We used the EquiFrame framework, adapted for disability and gender, and focusing on WASH and MHM. Ten Nepali policies and guidance documents were reviewed and scored for quality against the framework, which included 21 core concepts of human rights. We also interviewed key informants to consider the inclusion of disability in the implementation of MHM interventions. We applied stratified purpose sampling to 12 government officials and service providers working in Kathmandu and the Kavrepalanchock district; conducted in-depth interviews and analysed data thematically using Nvivo 11. RESULTS: Disability was inadequately covered within the policy documents, and MHM policy commitments for disability were almost non-existent. Participation of people with disabilities in policy development was limited; within Kavrepalanchok, policy commitments were not implemented as intended and disability service providers were unable to allocate government resources. Inadequate data on disability and MHM resulted in limited professional understanding of the issues, as service providers had no training. A narrow WASH infrastructure approach to improving MHM for people with disabilities was prioritised. MHM interventions were delivered in schools; these failed to reach children with disabilities who are often out of school. Finally, there were indications that some caregivers seek sterilisation for people with disabilities who are unable to manage menstruation independently. CONCLUSION: Though the Constitution of Nepal enshrines gender equality and disability inclusion, there are consistent gaps in attention to disability and MHM in policies and practice. These omit and exclude people with disabilities from MHM interventions. Investment is required to generate evidence on the MHM barriers faced by people with disabilities, which would then be drawn on to develop training on these issues for professionals to improve understanding. Subsequently, policy makers could include more concepts of human rights against disability in relevant policies and service providers could implement policy commitments as intended.

Qualitative study exploring the barriers to menstrual hygiene management faced by adolescents and young people with a disability, and their carers in the Kavrepalanchok district, Nepal.

BACKGROUND: Menstrual hygiene management (MHM) is a recognised public health, social and educational issue, which must be achieved to allow the realisation of human rights. People with disabilities are likely to experience layers of discrimination when they are menstruating, but little evidence exists. METHODS: The study aims to investigate barriers to MHM that people with disabilities and their carers face in the Kavrepalanchok, Nepal, using qualitative methods. Twenty people with disabilities, aged 15-24, who menstruate and experience 'a lot of difficulty' or more across one or more of the Washington Group functional domains were included, as well as 13 carers who provide menstrual support to these individuals. Purposeful sampling was applied to select participants. Different approaches were used to investigating barriers to MHM and triangulate data: in-depth interviews, observation, PhotoVoice and ranking. We analysed data thematically, using Nvivo 11. RESULTS: Barriers to MHM experienced by people with disabilities differ according to the impairment. Inaccessible WASH facilities were a major challenge for people with mobility, self-care and visual impairments. People with intellectual impairments had difficulty accessing MHM information and their carers despaired when they showed their menstrual blood to others, which could result in abuse. No support mechanisms existed for carers for MHM, and they felt overwhelmed and isolated. Menstrual discomfort was a major challenge; these were managed with home remedies, or not at all. Most participants followed menstrual restrictions, which were widespread and expected; many feared they would be cursed if they did not. As disability is often viewed as a curse, this demonstrates the layers of discrimination faced. CONCLUSION: Issues related to MHM for people with disabilities is more complex than for others in the population due to the additional disability discrimination and impairment experienced. Research exploring these issues must be conducted in different settings, and MHM interventions, tailored for impairment type and carers requirements,should be developed. Attention to, and resourcing for disability inclusive MHM must be prioritised to ensure 'no one is left behind'.

Primary health care facility readiness to implement primary eye care in Nigeria: equipment, infrastructure, service delivery and health management information systems.

BACKGROUND: Over two-thirds of Africans have no access to eye care services. To increase access, the World Health Organization (WHO) recommends integrating eye care into primary health care, and the WHO Africa region recently developed a package for primary eye care. However, there are limited data on the capacities needed for delivery, to guide policymakers and implementers on the feasibility of integration. The overall purpose of this study was to assess the technical capacity of the health system at primary level to deliver the WHO primary eye care package. Findings with respect to service delivery, equipment and health management information systems (HMIS) are presented in this paper. METHODS: This was a mixed-methods, cross sectional feasibility study in Anambra State, Nigeria. Methods included a desk review of relevant Nigerian policies; a survey of 48 primary health facilities in six districts randomly selected using two stage sampling, and semi-structured interviews with six supervisors and nine purposively selected facility heads. Quantitative study tools included observational checklists and questionnaires. Survey data were analysed descriptively using STATA V.15.1 (Statcorp, Texas). Differences between health centres and health posts were analysed using the z-test statistic. Interview data were analysed using thematic analysis assisted by Open Code Software V.4.02. RESULTS: There are enabling national health policies for eye care, but no policy specifically for primary eye care. 85% of facilities had no medication for eye conditions and one in eight had no vitamin A in stock. Eyecare was available in < 10% of the facilities. The services delivered focussed on maternal and child health, with low attendance by adults aged over 50 years with over 50% of facilities reporting ≤10 attendances per year per 1000 catchment population. No facility reported data on patients with eye conditions in their patient registers. CONCLUSION: A policy for primary eye care is needed which aligns with existing eye health policies. There are currently substantial capacity gaps in service delivery, equipment and data management which will need to be addressed if eye care is to be successfully integrated into primary care in Nigeria.

Human resource and governance challenges in the delivery of primary eye care: a mixed methods feasibility study in Nigeria.

BACKGROUND: To increase access to eye care, the World Health Organization's Africa Region recently launched a primary eye care (PEC) package for sub-Saharan Africa. To determine the technical feasibility of implementing this package, the capacity of health systems at primary level needs to be assessed, to identify capacity gaps that would need to be addressed to deliver effective and sustainable PEC. This study reports on the human resource and governance challenges for delivering PEC in Anambra State, Nigeria. METHODS: Design: This was a mixed methods feasibility study. A desk review of relevant Nigerian national health policy documents on both eye health and primary health care was conducted, and 48 primary health care facilities in Anambra state were surveyed. Data on human resource and governance in primary health facilities were collected using structured questionnaires and through observation with checklists. In-depth interviews were conducted with district supervisors and selected heads of facilities to explore the opportunities and challenges for the delivery of PEC in their facilities/districts. Data were analysed using the World Health Organization's health system framework. RESULTS: A clear policy for PEC is lacking. Supervision was conducted at least quarterly in 54% of facilities and 56% of facilities did not use the standard clinical management guidelines. There were critical shortages of health workers with 82% of facilities working with less than 20% of the number recommended. Many facilities used volunteers and/or ad hoc workers to mitigate staff shortages. CONCLUSION: Our study highlights the policy, governance and health workforce gaps that will need to be addressed to deliver PEC in Nigeria. Developing and implementing a specific policy for PEC is recommended. Implementation of existing national health policies may help address health workforce shortages at the primary health care level.

To be young, unmarried, rural, and female: intersections of sexual and reproductive health and rights in the Maldives.

This paper explores sexual and reproductive health and rights (SRHR) among young people, identifying intersecting factors that create inequities in access to services, health-seeking behaviour, and ultimately health outcomes. Based on qualitative interviews with young people in the Maldives, it demonstrates how these intersectional experiences are contrary to what is often assumed in official data, policies, and services. Three factors were found to shape young people's experiences: marital status, gender, and urban/rural differences. Non-marital sexual activity is illegal in the Maldives, but it is somewhat expected of unmarried men, while unmarried women are stigmatised for being sexually active. Although access to SRH services is restricted for all unmarried people, young women face additional difficulties, as the risk of being exposed is much greater in small island communities. Maldivian island communities are extremely small and characterised by an inward-looking culture that exerts considerable social pressure, particularly on unmarried women. For an unmarried woman, being known to be sexually active, or worse, pregnant outside of marriage, has severe social consequences including stigma and isolation from the community, and their own family. This concern is more prevalent among rural young women, as they live in smaller communities where stigma is inescapable. The need to avoid public scrutiny and humiliation contributes to making unsafe abortion a common solution for many unintended pregnancies. Failure to acknowledge these intersecting factors in SRHR experience and access has led to inequities among an already overlooked population, shaping their experiences, knowledge, health-seeking behaviour, and health outcomes.

Access to primary healthcare services for adults with disabilities in Latin America and the Caribbean: a review and meta-synthesis of qualitative studies.

PURPOSE: This review and meta-synthesis of qualitative studies aims to provide an overview of qualitative evidence on primary healthcare access of people with disability in Latin America and the Caribbean, as well as to identify barriers that exist in this region. METHODS: Six databases were searched for studies from 2000 to 2022. 34 qualitative studies were identified. RESULTS: Barriers exist on both demand and supply sides. The thematic synthesis process generated three broad overarching analytical themes, which authors have related to Levesque et al.'s aspects of "ability to perceive," "availability, accommodation and ability to reach" and "appropriateness and ability to engage." Access to information and health literacy are compromised due to a lack of tailored health education materials. Barriers in the urban environment, including inadequate transportation, and insufficient healthcare facility accessibility create challenges for people with disabilities to reach healthcare facilities independently. Attitudinal barriers contribute to suboptimal care experiences. CONCLUSION: People with disabilities face several barriers in accessing healthcare. Lack of healthcare provider training, inappropriate urban infrastructure, lack of accessible transport and inaccessibility in healthcare centers are barriers that need to be addressed. With these actions, people with disabilities will be closer to having their rights met.

The identification of barriers on both the supply and demand sides highlights implications for individuals with disabilities seeking access to primary healthcare services, primarily in Brazil, with similar concerns noted in Colombia and Trinidad and Tobago.Service providers should enhance access to people with disabilities by providing accessible information and reasonable accommodation for people with disabilities.More training of healthcare professionals is required to support the provision of care for people with disabilities.There is a need to improve healthcare centre accessibility, as well as local infrastructure and transportation to prevent people with disabilities from having their rights violated.Linkages should be strengthened between sectors like transportation, urban development, and health to enhance overall accessibility and prevent violations of the rights of individuals with disabilities.

Healthcare Stakeholders' Perspectives on Challenges in the Provision of Quality Primary Healthcare for People with Disabilities in Three Regions of Guatemala: A Qualitative Study.

It is estimated that 3.75 billion people worldwide lack access to healthcare services. Marginalized populations, such as people with disabilities, are at greater risk of exclusion. People with disabilities not only face the same barriers as people without disabilities, but also experience a range of additional barriers in accessing healthcare due to a variety of discriminatory and inaccessible environments. These extra barriers exist despite their greater need for general healthcare, as well as specialized healthcare related to their impairment. Few studies have focused on healthcare providers and the challenges they face in caring for this group. This paper describes the perspectives of healthcare stakeholders and reported challenges to the provision of quality primary healthcare for people with disabilities. In-depth interviews with 11 healthcare stakeholders were conducted in three regions of Guatemala. Data were analyzed using thematic analysis. Five sub-themes emerged from the above theme: infrastructure and availability of resources, impairment-based challenges, need for special attention and empathy, opportunity to provide services to people with disabilities, and gaps in training. The results could contribute to the development and implementation of strategies that can improve primary care provision and ultimately access to services for people with disabilities in low- and middle-income countries.

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

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

Assessing the capacity of primary health care facilities in Nigeria to deliver eye health promotion: Results of a mixed-methods feasibility study.

Over 25 million people in sub-Saharan Africa are blind or visually impaired, the majority from avoidable causes. Health promotion and disease prevention are important strategies for eye health, through good governance, health literacy and increasing access to eye care services. To increase equity in access for eyecare services, the World Health Organization Africa Region developed a package of interventions for primary eye care, which includes health promotion. The aim of this study was to assess the capacity of the primary healthcare system to deliver health promotion for eye care in Nigeria. Mixed methods were used during a survey of 48 government-owned primary health care facilities in Anambra state, Nigeria: interviews with district health supervisors, facility staff and village health workers, and a desk review of policy documents for primary health care and eye care in Nigeria. Findings were benchmarked against the capacities needed to deliver health promotion agreed through a Delphi exercise and were analysed using the World Health Organization's health system building blocks. Eye health promotion policies exist but are fragmented across different national health policies. Health promotion activities focussed on "mobilising" community members to access care provided in facilities, particularly for women of childbearing age and young children, and health education was limited. Only one in ten facilities engaged the elderly and a fifth delivered health promotion for eye care. Health promotion activities were supervised in 43.2% of facilities and transport to remote areas was limited. A robust eye health promotion strategy needs to be included in the National Eye Health Policy. The scope of existing health promotion will need to expand to include eye conditions and different age groups. Increasing eye health literacy should be emphasized. Governance, training health workers in eye health promotion, educational materials, and transport to visit communities will also be needed.

Disabled people in Britain and the impact of the COVID-19 pandemic.

This paper reports on in-depth qualitative interviews conducted with 69 disabled people in England and Scotland, and with 28 key informants from infrastructure organisations in the voluntary and statutory sectors, about the impact of COVID-19, and measures taken to control it. Participants were recruited through voluntary organisations. As with everyone, the Pandemic has had a huge impact: we discuss the dislocations it has caused in everyday life; the failures of social care; the use of new technologies; and participants' view on leadership and communication. We conclude with suggestions for urgent short term and medium term responses, so that the United Kingdom and other countries can respond better to this and other pandemics, and build a more inclusive world.

Disability and the achievement of Universal Health Coverage in the Maldives.

OBJECTIVE: To assess access to general and disability-related health care among people with disabilities in the Maldives. METHODS: This study uses data from a case-control study (n = 711) nested within a population-based, nationally representative survey to compare health status and access to general healthcare amongst people with and without disabilities. Cases and controls were matched by gender, location and age. Unmet need for disability-related healthcare is also assessed. Multivariate regression was used for comparisons between people with and without disabilities. RESULTS: People with disabilities had poorer levels of health compared to people without disabilities, including poorer self-rated health, increased likelihood of having a chronic condition and of having had a serious health event in the previous 12 months. Although most people with and without disabilities sought care when needed, people with disabilities were much more likely to report difficulties when routinely accessing healthcare services compared to people without disabilities. Additionally, 24% of people with disabilities reported an unmet need for disability-related healthcare, which was highest amongst people with hearing, communication and cognitive difficulties, as well as amongst older adults and people living in the lowest income per capita quartile. Median healthcare spending in the past month was modest for people with and without disabilities. However, people with disabilities appear to have high episodic healthcare costs, such as for disability-related healthcare and when experiencing a serious health event. CONCLUSIONS: This study found evidence that people with disabilities experience unmet needs for both disability-related and general healthcare. There is therefore evidence that people with disabilities in the Maldives are falling behind in core components relevant to UHC: availability of all services needed, and quality and affordability of healthcare.

Safe care for premature babies at home: Parenting and stimulating development.

Parental daily care and adequate stimuli are extremely important for development and safety of premature babies at home. This study aimed to analyze safe home care for babies born under 32 weeks from parents' perspectives, with a view to a longitudinal promotion of baby development. A qualitative study, based on philosophical hermeneutic approach proposed by Hans-Georg Gadamer, in which dialogue as a principle provides understanding and fusion of experiences and knowledge. Semi-structured interviews were conducted with 18 parents of premature babies under 1 year of age. Thematic analysis proposed by Braun and Clarke was applied using an inductive approach. Elements related to safe care were identified: home arrival, safe home care: preserving baby health and development, support for safe home care, and development of parental care to promote baby safety. These elements can provide a basis for safe home care that needs to be reinforced longitudinally to increase particularities of baby protection, avoid accidents and illnesses, and improve appropriate developmental stimuli and positive parenting.

Participatory Visual Methods with caregivers of children with Congenital Zika Syndrome in Colombia: A case study.

Background: This study explores the acceptability and feasibility of the use of two different Participatory Visual Methods (Participatory Video and Digital Storytelling) in gathering information on the experiences and perspectives of carers of children with Congenital Zika Syndrome within Colombia. Methods: Participatory Video was used to assess the impact of the Juntos parent-support intervention in the lives of carers, and Digital Storytelling was used to explore the healthcare access for these children. In-depth interviews were conducted to probe participants on their views of these methods. Results: One Participatory Video was produced and four Digital Stories. Of the initial eight caregivers who took part in the Participatory Video process, four completed both the Digital Storytelling process and an in-depth interview about their experiences. The main factors shaping participants' experiences related to the skills learned in making the videos, the feeling of collectiveness and the control over the processes. Conclusions: Women with children with Congenital Zika Syndrome have reported feeling marginalised and misunderstood in daily life. This case study found that Participatory Visual Methods is acceptable and feasible. Moreover, these approaches can support groups in different aspects, such as providing a space to share their stories creatively, hear others in similar situations as them and increase the feeling of community.

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

OBJECTIVES: To estimate the prevalence of disability among Syrian refugees living in Sultanbeyli district, Istanbul and compare people with and without disabilities in terms of demographic and socio-economic characteristics. METHODS: Using the municipality refugee database as the sampling frame, 80 clusters of 50 people (aged 2+ years) were selected using probability proportionate to size sampling of clusters and random selection of households within clusters. Disability assessment included: i) self-reported difficulties in functioning (using the Washington Group Short Set-Enhanced tool and Child Functioning Modules), ii) Rapid Assessment of Musculoskeletal Impairment and iii) screening for symptoms of common mental disorders for children aged 8-17. RESULTS: The overall prevalence of disability was 24.7% (95% CI 22.1-27.4), when including people self-reporting a lot of difficulty/cannot do in at least functional domain (15%, 95% CI 13.1-17.2), moderate/severe MSI (8.7%, 95% CI 7.6-9.9), and/or symptomatic anxiety, depression and PTSD among children 8-17 (21.0%, 95% CI 18.2-23.9). Men with disabilities were significantly less likely to be in paid work compared to their peers without disabilities (aOR 0.3 95% CI 0.2-0.5). Overall 60% of households included at least one person with a disability. Households with at least one person with a disability had a significantly higher dependency ratio, lower proportion of working-age adults in paid work, and were more likely to be female headed and in receipt of social protection schemes (p<0.05). CONCLUSION: Disability is common among Syrian refugees in Sultanbeyli. People with disabilities in this setting experience greater vulnerability to poverty and exclusion from work, highlighting an urgent need for inclusive services, programmes and policies that are developed and implemented in partnership with people with disabilities.

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

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

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

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

The Technical Feasibility of Integrating Primary Eye Care Into Primary Health Care Systems in Nigeria: Protocol for a Mixed Methods Cross-Sectional Study.

BACKGROUND: Approximately 90% of the 253 million blind or visually impaired people worldwide live in low- and middle-income countries. Lack of access to eye care is why most people remain or become blind. The World Health Organization Regional Office for Africa (WHO-AFRO) recently launched a primary eye care (PEC) package for sub-Saharan Africa-the WHO-AFRO PEC package-for integration into the health system at the primary health care (PHC) level. This has the potential to increase access to eye care, but feasibility studies are needed to determine the extent to which the health system has the capacity to deliver the package in PHC facilities. OBJECTIVE: Our objective is to assess the technical feasibility of integrating the WHO-AFRO PEC package in PHC facilities in Nigeria. METHODS: This study has several components, which include (1) a literature review of PEC in sub-Saharan Africa, (2) a Delphi exercise to reach consensus among experts regarding the technical complexity of the WHO-AFRO PEC package and the capacities needed to deliver it in PHC facilities, (3) development of PEC technical capacity assessment tools, and (4) data collection, including facility surveys and semistructured interviews with PHC staff and their supervisors and village health workers to determine the capacities available to deliver PEC in PHC facilities. Analysis will identify opportunities and the capacity gaps that need to be addressed to deliver PEC. RESULTS: Consensus was reached among experts regarding the technical complexity of the WHO-AFRO PEC package and the capacities needed to deliver it as part of PHC. Quantitative tools (ie, structured questionnaires, in-depth interviews, and observation checklists) and topic guides based on agreed-upon technical capacities have been developed and relevant stakeholders have been identified. Surveys in 48 PHC facilities and interviews with health professionals and supervisors have been undertaken. Capacity gaps are being analyzed. CONCLUSIONS: This study will determine the capacity of PHC centers to deliver the WHO-AFRO PEC package as an integral part of the health system in Nigeria, with identification of capacity gaps. Although capacity assessments have to be context specific, the tools and findings will assist policy makers and health planners in Nigeria and similar settings, who are considering implementing the package, in making informed choices. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17263.

From words to actions: systematic review of interventions to promote sexual and reproductive health of persons with disabilities in low- and middle-income countries.

INTRODUCTION: Persons with disabilities have the same sexual and reproductive health and rights (SRHR) as non-disabled persons. Yet they face numerous barriers in their access to sexual and reproductive health services and their rights are often not met. Evidence on SRHR for persons with disabilities is sparse, particularly evaluations of interventions demonstrating 'what works.' This systematic review assessed interventions to promote SRHR for persons with disabilities in low- and middle-income countries. METHODS: We searched for qualitative, quantitative or mixed method observational studies representing primary research, published between 2010 and 2019, using MEDLINE, Embase, PubMed, Global Health and CINAHL Plus. Search strings were compiled for different elements of SRHR and for all forms of disability. 24,919 records were screened, leading to over 380 relevant papers, most of which were descriptive, focussing on needs and barriers to SRHR needs being fulfilled. Of the 33 full-text articles assessed for eligibility, 18 were included in the synthesis. All included studies were assessed for bias and quality of evidence, using STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) and RATS (relevance, appropriateness, transparency andsoundness) tools. Among the 16 interventions (from 18 articles), 25% had low risk of bias, 31% had moderate risk of bias and 44% had high risk of bias. Data analysis used narrative synthesis; a method suited for systematic reviews with heterogeneous studies. We used Levesque healthcare access model to analyse the focus of interventions. RESULTS: 11 interventions were from upper middle-income settings; two from lower-income settings; only one operated in rural areas. Interventions addressed intellectual impairment (6), visual impairment (6), hearing impairment (4), mental health conditions (2) and physical impairments (2). Most interventions (15/16) focus on information provision and awareness raising. We could not identify any intervention promoting access to maternal health, family planning and contraception, or safe abortion for people with disabilities. CONCLUSION: This systematic review has highlighted stark gaps in evidence. More rigorous evaluations are needed.