Inclusion of people with disabilities in Chilean health policy: a policy analysis.

BACKGROUND: Around 18% of the population in Chile has disabilities. Evidence shows that this population has greater healthcare needs, yet they face barriers to accessing healthcare due to health system failures. This paper aims to assess the inclusion of people with disabilities in health policy documents and to explore the perceptions of key national stakeholders regarding the policy context, policy processes, and actors involved. METHODS: A policy content analysis was conducted of 12 health policy documents using the EquiFrame framework, adapted to assess disability inclusion. Documents were reviewed and rated on their quality of commitment against 21 core concepts of human rights in the framework. Key national stakeholders (n = 15) were interviewed, and data were thematically analysed under the Walt and Gilson Policy Analysis Triangle, using NVivo R1. RESULTS: Core human rights concepts of disability were mentioned at least once in nearly all health policy documents (92%). However, 50% had poor policy commitments for disability. Across policies, Prevention of health conditions was the main human rights concept reflected, while Privacy of information was the least referenced concept. Participants described a fragmented disability movement and health policy, related to a dominant biomedical model of disability. It appeared that disability was not prioritized in the health policy agenda, due to ineffective mainstreaming of disability by the Government and the limited influence and engagement of civil society in policy processes. Moreover, the limited existing policy framework on disability inclusion is not being implemented effectively. This implementation gap was attributed to lack of financing, leadership, and human resources, coupled with low monitoring of disability inclusion. CONCLUSIONS: Improvements are needed in both the development and implementation of disability-inclusive health policies in Chile, to support the achievement of the right to healthcare for people with disabilities and ensuring that the health system truly "leaves no one behind".

INTRODUCCIóN: Alrededor del 18% de la población de Chile tiene discapacidad. Los datos demuestran que esta población tiene mayores necesidades de salud, pero se enfrenta a barreras para acceder a la salud debido a las deficiencias del sistema sanitario. El objetivo de este estudio es evaluar la inclusión de las personas con discapacidad en las políticas sanitarias y explorar las percepciones de actores nacionales en relación al contexto político, los procesos políticos y los actores implicados. MéTODOS: Se realizó un análisis de contenido de 12 políticas sanitarias utilizando el marco EquiFrame, adaptado para discapacidad. Se calificó la calidad de compromiso de las políticas con respecto a 21 conceptos de derechos humanos del EquiFrame. Se entrevistó a 15 actores nacionales, y los datos se analizaron temáticamente según el Triángulo de Políticas de Walt y Gilson, utilizando NVivo R1. RESULTADOS: Los conceptos de derechos humanos en materia de discapacidad se mencionaron al menos una vez en casi todas las políticas sanitarias (92%). Sin embargo, en el 50% de los casos los compromisos políticos en materia de discapacidad eran escasos. En todas las políticas, la Prevención de los problemas de salud fue el principal concepto de derechos humanos reflejado, mientras que la Privacidad de la información fue el concepto menos mencionado. Los participantes describieron un movimiento de la discapacidad y una política sanitaria fragmentados, relacionados con un modelo biomédico dominante de la discapacidad. Pareciera que la discapacidad no es prioritaria en la agenda política sanitaria, debido a su ineficaz integración por parte del Gobierno y a la limitada participación de la sociedad civil en los procesos políticos. Además, el limitado marco político existente sobre salud inclusiva no se está implementando eficazmente. Esta deficiencia en la implementación se atribuyó a la falta de financiamiento, liderazgo y recursos humanos, junto con el escaso monitoreo de la discapacidad. CONCLUSIONES: Se requieren mejoras tanto en el desarrollo como en la implementación de políticas de salud inclusivas de la discapacidad en Chile, para apoyar el alcance del derecho a la salud de las personas con discapacidad y asegurar que el sistema de salud realmente "no deje a nadie atrás".

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.

Childhood disability in rural Niger: a population-based assessment using the Key Informant Method.

BACKGROUND: Data on childhood disability is essential for planning health, education and other services. However, information is lacking in many low- and middle-income countries, including Niger. This study uses the Key Informant Method, an innovative and cost-effective strategy for generating population-based estimates of childhood disability, to estimate the prevalence and causes of moderate/severe impairments and disabling health conditions in children of school-going age (7-16 years) in the Kollo department of western Niger. METHODS: Community-based key informants were trained to identify children who were suspected of having the impairment types/health conditions included in this study. Children identified by key informants were visited by paediatricians and underwent an assessment for moderate/severe vision, hearing, physical and intellectual impairments, as well as epilepsy, albinism and emotional distress. RESULTS: Two thousand, five hundred sixty-one children were identified by key informants, of whom 2191 were visited by paediatricians (response rate = 85.6%). Overall, 597 children were determined to have an impairment/health condition, giving a prevalence of disability of 11.4 per 1000 children (10.6- 12.2). Intellectual impairment was most common (6.5 per 1000), followed by physical (4.9 per 1000) and hearing impairments (4.7 per 1000). Many children had never sought medical attention for their impairment/health condition, with health seeking ranging from 40.0% of children with visual impairment to 67.2% for children with physical impairments. CONCLUSION: The Key Informant Method enabled the identification of a large number of children with disabling impairments and health conditions in rural Niger, many of whom have unmet needs for health and other services.

Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries.

The one billion people living with disabilities globally already face a heightened risk of poverty, which will likely be exacerbated by the COVID-19 pandemic unless interventions to address its economic impacts are disability-inclusive. This paper draws on the literature on disability, poverty and social protection in low- and middle-income countries to explore the pathways through which the current pandemic may increase the risk of poverty amongst people with disabilities, such as loss of income from disruptions to work, particularly in the informal sector, and higher future spending and productivity losses from disruptions to healthcare and other key services (e.g. rehabilitation, assistive devices). It also explores how social protection and other initiatives to mitigate the economic impacts of the pandemic should consider the needs of people with disabilities, with recommendations for disability-inclusive actions in the design and implementation of eligibility criteria and application procedures, as well as the delivery and content of benefits. Across recommendations, meaningful consultations with people with disabilities, leadership at the program and policy level, appropriate budgeting and monitoring of progress through routine collection of data on disability are key for improving access to and impact of economic responses amongst people with disabilities.

Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review.

BACKGROUND: One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC. METHODS: We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care. RESULTS: The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments. CONCLUSION: Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.

How to conduct good quality research on violence against children with disabilities: key ethical, measurement, and research principles.

BACKGROUND: Approximately one billion children experience violence every year. Violence against children is an urgent global public health concern and violation of children's rights. It is also a risk factor for serious negative health and social outcomes and is therefore addressed within the Sustainable Development Goals (SDGs). Children with disabilities, who make up one in 20 children worldwide, are particularly vulnerable to violence although good quality data are lacking on causes and means of prevention of violence against children with disabilities. Key challenges exist in the measurement of disability and violence, which in part explains the dearth in evidence. IMPROVING RESEARCH ON VIOLENCE AGAINST CHILDREN WITH DISABILITIES: This paper provides guidance on how to conduct good quality, ethical, and inclusive research on violence against children with disabilities, particularly in low-income settings. The lack of an international agreed 'gold standard' frustrates efforts to measure violence across settings and time. Careful consideration must be given to the design of survey tools. Qualitative and participatory research methods also offer important opportunities to explore children's subjective understanding and experiences of violence. Challenges also exist around the measurement of disability. Disability may be measured by asking directly about disability, through self-reported functioning, or through the presence of impairments or health conditions. These approaches have strengths and limitations and should build on what children are able to do and include appropriate adaptations for specific impairments where necessary. Ethical research also requires adherence to ethical guidelines and approvals, obtaining informed consent, appropriate child protection responses, and careful consideration of interviewer-related issues including their selection, training, and welfare. Key methodological gaps remain - how to include children with severe communication challenges in research; how to respond in instances of weak child protection systems; designing sampling procedures that adequately represent children with disabilities in large-scale violence surveys; and determining how best to ask about violence safely in large-scale surveys and monitoring data. This paper further advocates for the dissemination of research results in inclusive and accessible formats. CONCLUSION: With careful planning, challenges in collecting data on disability and violence can be overcome to generate evidence in this neglected area.

Correction to: Childhood disability in Malawi: a population based assessment using the key informant method.

Following the publication of this article [1] it was brought to our attention that inadvertently the COSECSA Oxford Orthopaedic Link (COOL) programme was not acknowledged for funding this study.

Childhood disability in Malawi: a population based assessment using the key informant method.

BACKGROUND: Epidemiological data on childhood disability are lacking in Low and Middle Income countries (LMICs) such as Malawi, hampering effective service planning and advocacy. The Key Informant Method (KIM) is an innovative, cost-effective method for generating population data on the prevalence and causes of impairment in children. The aim of this study was to use the Key Informant Method to estimate the prevalence of moderate/severe, hearing, vision and physical impairments, intellectual impairments and epilepsy in children in two districts in Malawi and to estimate the associated need for rehabilitation and other services. METHODS: Five hundred key informants (KIs) were trained to identify children in their communities who may have the impairment types included in this study. Identified children were invited to attend a screening camp where they underwent assessment by medical professionals for moderate/severe hearing, vision and physical impairments, intellectual impairments and epilepsy. RESULTS: Approximately 15,000 children were identified by KIs as potentially having an impairment of whom 7220 (48%) attended a screening camp. The estimated prevalence of impairments/epilepsy was 17.3/1000 children (95% CI: 16.9-17.7). Physical impairment (39%) was the commonest impairment type followed by hearing impairment (27%), intellectual impairment (26%), epilepsy (22%) and vision impairment (4%). Approximately 2100 children per million population could benefit from physiotherapy and occupational therapy and 300 per million are in need of a wheelchair. An estimated 1800 children per million population have hearing impairment caused by conditions that could be prevented or treated through basic primary ear care. Corneal opacity was the leading cause of vision impairment. Only 50% of children with suspected epilepsy were receiving medication. The majority (73%) of children were attending school, but attendance varied by impairment type and was lowest among children with multiple impairments (38%). CONCLUSION: Using the KIM this study identified more than 2500 children with impairments in two districts of Malawi. As well as providing data on child disability, rehabilitation and referral service needs which can be used to plan and advocate for appropriate services and interventions, this method study also has an important capacity building and disability awareness raising component.

The relationship between HIV and prevalence of disabilities in sub-Saharan Africa: systematic review (FA).

OBJECTIVE: To systematically review evidence on the prevalence and risk of disabilities among children and adults living with HIV in sub-Saharan Africa. METHODS: Articles were identified from 1980 to June 2013 through searching seven electronic databases. Epidemiological studies conducted in sub-Saharan Africa that explored the association between HIV status and general disability or specific impairments, with or without an HIV-uninfected comparison group, were eligible for inclusion. RESULTS: Of 12 867 records initially identified, 61 papers were deemed eligible for inclusion. The prevalence of disability was high across age groups, impairment types and study locations. Furthermore, 73% of studies using an HIV- comparator found significantly lower levels of functioning in people living with HIV (PLHIV). By disability type, the results were as follows: (i) for studies measuring physical impairments (n = 14), median prevalence of limitations in mobility and motor function among PLHIV was 25.0% (95% CI: 21.8-28.2%). Five of eight comparator studies found significantly reduced functioning among PLHIV; for arthritis, two of three studies which used an HIV- comparison group found significantly increased prevalence among PLHIV; (ii) for sensory impairment studies (n = 17), median prevalence of visual impairment was 11.2% (95%CI: 9.5-13.1%) and hearing impairment was 24.1% (95%CI: 19.2-29.0%) in PLHIV. Significantly increased prevalence among PLHIV was found in one of four (vision) and three of three studies (hearing) with comparators; (iii) for cognitive impairment in adults (n = 30), median prevalence for dementia was 25.3% (95% CI: 22.0-28.6%) and 40.9% (95% CI: 37.7-44.1%) for general cognitive impairment. Across all types of cognitive impairment, twelve of fourteen studies found a significant detrimental effect of HIV infection; (iv) for developmental delay in children with HIV (n = 20), median prevalence of motor delay was 67.7% (95% CI: 62.2-73.2%). All nine studies that included a comparator found a significant difference between PLHIV and controls; for cognitive development and global delay, a significant detrimental effect of HIV was found in five of six and one of two studies, respectively. In the nine cohort studies comparing vertically infected and uninfected children, eight showed a significant gap in development over time in children with HIV. Finally, fifteen of thirty-one (48%) studies found a statistically significant dose-response relationship between indicators of disease progression (CD4 or WHO stage) and disability. CONCLUSIONS: HIV is widespread in sub-Saharan Africa and the evidence suggests that it is linked to disabilities, affecting a range of body structures and functions. More research is needed to better understand the implications of HIV-related disability for individuals, their families as well as those working in the fields of disability and HIV so that appropriate interventions can be developed.

The association between disability and mortality: a mixed-methods study.

BACKGROUND: Globally, 1·3 billion people have a disability and are more likely to experience poor health than the general population. However, little is known about the mortality or life expectancy gaps experienced by people with disabilities. We aimed to undertake a systematic review and meta-analysis of the association between disability and mortality, compare these findings to the evidence on the association of impairment types and mortality, and model the estimated life expectancy gap experienced by people with disabilities. METHODS: We did a mixed-methods study, which included a systematic review and meta-analysis, umbrella review, and life expectancy modelling. For the systematic review and meta-analysis, we searched MEDLINE, Global Health, PsycINFO, and Embase for studies published in English between Jan 1, 2007, and June 7, 2023, investigating the association of mortality and disability. We included prospective and retrospective cohort studies and randomised controlled trials with a baseline assessment of disability and a longitudinal assessment of all-cause mortality or cause-specific mortality. Two reviewers independently assessed study eligibility, extracted the data, and assessed risk of bias. We did a random-effects meta-analysis to calculate a pooled estimate of the mortality rate ratio for people with disabilities compared with those without disabilities. We did an umbrella review of meta-analyses examining the association between different impairment types and mortality. We used life table modelling to translate the mortality rate ratio into an estimate of the life expectancy gap between people with disabilities and the general population. The systematic review and meta-analysis is registered with PROSPERO, CRD42023433374. FINDINGS: Our search identified 3731 articles, of which 42 studies were included in the systematic review. The meta-analysis included 31 studies. Pooled estimates showed that all-cause mortality was 2·24 times (95% CI 1·84-2·72) higher in people with disabilities than among people without disabilities, although heterogeneity between the studies was high (τ2=0·28, I2=100%). Modelling indicated a median gap in life expectancy of 13·8 years (95% CI 13·1-14·5) by disability status. Cause-specific mortality was also higher for people with disabilities, including for cancer, COVID-19, cardiovascular disease, and suicide. The umbrella review identified nine meta-analyses, which showed consistently elevated mortality rates among people with different impairment types. INTERPRETATION: Mortality inequities experienced by people with disabilities necessitate health system changes and efforts to address inclusion and the social determinants of health. FUNDING: National Institute for Health and Care Research, Rhodes Scholarship, Indonesia Endowment Funds for Education, Foreign, Commonwealth and Development Office (Programme for Evidence to Inform Disability Action), and the Arts and Humanities Research Council.

HIV knowledge and access to testing for people with and without disabilities in low- and middle-income countries: evidence from 37 Multiple Indicator Cluster Surveys.

INTRODUCTION: Disability and HIV are intricately linked, as people with disabilities are at higher risk of contracting HIV, and living with HIV can lead to impairments and disability. Despite this well-established relationship, there remains limited internationally comparable evidence on HIV knowledge and access to testing for people with disabilities. METHODS: We used cross-sectional data from 37 Multiple Indicator Cluster Surveys. Surveys were from six UNICEF regions, including East Asia and Pacific (n = 6), East and Central Asia (n = 7), Latin America and the Caribbean (n = 6), Middle East and North Africa (n = 4), South Asia (n = 2) and sub-Saharan Africa (n = 12). A total of 513,252 people were eligible for inclusion, including 24,695 (4.8%) people with disabilities. We examined risk ratios and 95% confidence intervals for key indicators on HIV knowledge and access to testing for people with disabilities by sex and country. We also conducted a meta-analysis to get a pooled estimate for each sex and indicator. RESULTS: Men and women with disabilities were less likely to have comprehensive knowledge about HIV prevention (aRR: 0.74 [0.67, 0.81] and 0.75 [0.69, 0.83], respectively) and to know of a place to be tested for HIV (aRR: 0.95 [0.92, 0.99] and 0.94 [0.92, 0.97], respectively) compared to men and women without disabilities. Women with disabilities were also less likely to know how to prevent mother-to-child transmission (aRR: 0.87 [0.81, 0.93]) and ever have been tested for HIV (aRR: 0.90 [0.85, 0.94]). CONCLUSIONS: Men and women with disabilities have lower overall HIV knowledge and in particular women with disabilities also indicate lower testing rates. Governments must include people with disabilities in HIV programmes by improving disability-inclusion and accessibility to HIV-related information, education and healthcare services.

Building disability-inclusive health systems.

Health systems often fail people with disabilities, which might contribute to their shorter life expectancy and poorer health outcomes than people without disabilities. This Review provides an overview of the existing evidence on health inequities faced by people with disabilities and describes existing approaches to making health systems disability inclusive. Our Review documents a broad range of health-care inequities for people with disabilities (eg, lower levels of cancer screening), which probably contribute towards health differentials. We identified 90 good practice examples that illustrate current strategies to reduce inequalities. Implementing such strategies could help to ensure that health systems can expect, accept, and connect people with disabilities worldwide, deliver on their right to health, and achieve health for all.

Access to general health care among people with disabilities in Latin America and the Caribbean: a systematic review of quantitative research.

In Latin America and the Caribbean (LAC), there are 85 million people with disabilities (PwD). They often experience barriers accessing healthcare and die, on average, 10-20 years earlier than those without disabilities. This study aimed to systematically review the quantitative literature on access to general healthcare among PwD, compared to those without disabilities, in LAC. A systematic review and narrative synthesis was conducted. We searched in EMBASE, MEDLINE, LILACS, MedCarib, PsycINFO, SciELO, CINAHL, and Web of Science. Eligible articles were peer-reviewed, published between January 2000 and April 2023, and compared healthcare access (utilization, coverage, quality, affordability) between PwD and without disabilities in LAC. The search retrieved 16,538 records and 30 studies were included, most of which had a medium or high risk of bias (n = 23; 76%). Overall, the studies indicated that PwD use healthcare services more than those without disabilities. Some evidence indicated that women with disabilities were less likely to have received cancer screening. Limited evidence showed that health services affordability and quality were lower among PwD. In LAC, PwD appear to experience health inequities, although large gaps exist in the current evidence. Harmonization of disability and health access data collection is urgently needed to address this issue.

Effect of COVID-19 on livelihoods of people with and without disabilities: Results from a cross-sectional survey in 3 urban areas of Viet Nam.

BACKGROUND: The COVID-19 pandemic has had widespread health, social and economic impacts worldwide. In many contexts, it has likely exacerbated existing inequalities. OBJECTIVE: This study compares the economic impacts of the COVID-19 pandemic amongst people with and without disabilities in Viet Nam. METHODS: A telephone survey was conducted in the three largest cities of Viet Nam (Da Nang, Ha Noi, and Ho Chi Minh City) between December 2021 and January 2022. Participants were recruited through convenience sampling (n = 898; 479 people with disabilities; 419 without). The survey collected data on livelihoods, employment, household economic security, and access to social protection and assistance. RESULTS: People with disabilities were three times more likely to have stopped working completely (PR: 2.8, 95 % CI: 2.0-4.0), 30 % more likely to report reduced earnings (PR: 1.3, 95 % CI: 1.2-1.5), twice as likely to report severe impacts on household finances (PR: 1.9, 95 % CI: 1.6-2.3) and three times more likely to report severe impacts on household food security (PR: 3.2, 95 % CI: 2.3-4.6) since the onset of the pandemic. Amongst people with disabilities, informal workers were particularly negatively affected. Households with members with disabilities were more likely to receive some types of COVID-19-related assistance (e.g. financial or food aid), but less likely to be enrolled in social insurance. CONCLUSIONS: Urgent and inclusive responses are necessary during crises to address the unique challenges faced by people with disabilities. Implementing comprehensive social protection measures is crucial to narrowing disparities, and maintaining well-being and economic security during shocks such as COVID-19.

Improving access to family planning for women with disabilities in Kaduna city, Nigeria: study protocol for a pragmatic cluster-randomized controlled trial with integrated process evaluation.

BACKGROUND: Globally, women with disabilities are less likely to have access to family planning services compared to their peers without disabilities. However, evidence of effective interventions for promoting their sexual and reproductive health and rights remains limited, particularly in low- and middle-income settings. To help address disparities, an inclusive sexual and reproductive health project was developed to increase access to modern contraceptive methods and reduce unmet need for family planning for women of reproductive age with disabilities in Kaduna city, Nigeria. The project uses demand-side, supply-side and contextual interventions, with an adaptive management approach. This protocol presents a study to evaluate the project's impact. METHODS: A pragmatic cluster-randomized controlled trial design with surveys at baseline and endline will be used to evaluate interventions delivered for at least 1 year at health facility and community levels in comparison to 'standard' state provision of family planning services, in the context of state-wide and national broadcast media and advocacy. Randomization will be conducted based on the health facility catchment area, with 19 clusters in the intervention arm and 18 in the control arm. The primary outcome measure will be access to family planning. It was calculated that at least 950 women aged 18 to 49 years with disabilities (475 in each arm) will be recruited to detect a 50% increase in access compared to the control arm. For each woman with disabilities enrolled, a neighbouring woman without disabilities in the same cluster and age group will be recruited to assess whether the intervention has a specific effect amongst women with disabilities. The trial will be complemented by an integrated process evaluation. Ethical approval for the study has been given by the National Health Research Ethics Committee of Nigeria and London School of Hygiene & Tropical Medicine. DISCUSSION: Defining access to services is complex, as it is not a single variable that can be measured directly and need for family planning is subjectively defined. Consequently, we have conceptualized 'access to family planning' based on a composite of beliefs about using services if needed. TRIAL REGISTRATION: ISRCTN registry ISRCTN12671153. Retrospectively registered on 17/04/2023.

Evaluation of a disability-inclusive ultra-poor graduation programme in Uganda: study protocol for a cluster-randomised controlled trial with process evaluation.

BACKGROUND: There is little evidence on how to support ultra-poor people with disabilities to adopt sustainable livelihoods. The Disability-Inclusive Graduation (DIG) programme targets ultra-poor people with disabilities and/or women living in rural Uganda. The programme is an adaptation of an ultra-poor graduation model that has been shown to be effective in many contexts but not evaluated for people with disabilities. METHODS: The DIG programme works with project participants over a period of 18 months. Participants receive unconditional cash transfers for 6 months, training, access to savings-and-loans groups, and a capital asset that forms the basis of their new livelihood. The programme is also adapted to address specific barriers that people with disabilities face. Eligible households are clustered by geographical proximity in order to deliver the intervention. Eligibility is based on household screening to identify the 'ultra-poor' based on proxy means testing-both households with and without people with disabilities are included in the programme. Clusters are randomly selected prior to implementation, resulting in 96 intervention and 89 control clusters. The primary outcome of the trial is per-capita household consumption. Before the start of the intervention, a baseline household survey is conducted (November 2020) among project participants and those not offered the programme, a similar endline survey is conducted with participants with disabilities at the end of programme implementation in July 2022, and a second endline survey for all participants in October 2023. These activities are complemented by a process evaluation to understand DIG programme implementation, mechanisms, and context using complementary qualitative and quantitative methods. Ethical approval for the research has been received from Mildmay Uganda Research Ethics Committee and London School of Hygiene and Tropical Medicine. DISCUSSION: DIG is a promising intervention to evaluate for people with disabilities, adapted to be disability inclusive across programme components through extensive consultations and collaboration, and has proven efficacy at reducing poverty in other marginalised groups. However, evaluating a well-evidenced intervention among a new target group poses ethical considerations. TRIAL REGISTRATION: Registry for International Development Impact Evaluations, RIDIE-STUDY-ID-626008898983a (20/04/22). ISRCTN registry, ISRCTN78592382 . Retrospectively registered on 17/08/2023.

Prevalence of functional difficulty among school-aged children and effect on school enrolment in rural southern India: A cross-sectional analysis.

Despite the large number of children in India, there is little information on the impact of children's disability on school enrolment, and how this differs by population. We estimated the prevalence of childhood disability in two sites in Tamil Nadu, southern India, and the effect of functional difficulty on school enrolment. We used a parent-reported survey containing the UNICEF-Washington Group questions to identify children aged 5 to 17 years with functional difficulty during a census conducted for an ongoing trial. We estimated pooled- and gender-specific prevalence of functional difficulty among 29,044 children. We fitted regression models to identify subgroups with higher rates of functional difficulty and the effect of functional difficulty on reported school enrolment. We estimated the modification of the effect of functional difficulty by age, gender, socioeconomic status, household education, and sub-site, on additive and multiplicative scales. We found of 29,044 children, 299 (1.0%) had any functional difficulty, equal among boys and girls. Being understood (0.5%) and walking (0.4%) were the most common difficulties. Functional difficulty was strongly associated with non-enrolment in school (Prevalence ratio [PR] 4.59, 95% CI: 3.87, 5.43) after adjusting for age, gender, and site. We show scale-dependent differences between age and socioeconomic groups in the effect of functional difficulty on enrolment. This study shows that at least one in a hundred children in this region have severe functional difficulties and nearly half of these children are not enrolled in school, highlighting the need for further efforts and evidence-based interventions to increase school enrolment among these groups.

Impact evaluation of a cash-plus programme for children with disabilities in the Xiengkhouang Province in Lao PDR: study protocol for a non-randomised controlled trial.

INTRODUCTION: More than 170 countries have implemented disability-targeted social protection programmes, although few have been rigorously evaluated. Consequently, a non-randomised controlled trial is being conducted of a pilot 'cash-plus' programme implemented by UNICEF Laos and the Laos government for children with disabilities in the Xiengkhouang Province in Laos. The intervention combines a regular cash transfer with provision of assistive devices and access for caregivers to a family support programme. METHODS AND ANALYSIS: The non-randomised controlled trial will involve 350 children with disabilities across 3 districts identified by programme implementers as eligible for the programme (intervention arm). Implementers have also identified approximately 180 children with disabilities in neighbouring districts, who would otherwise meet eligibility criteria but do not live in the project areas (control arm). The trial will assess the impact of the programme on child well-being (primary outcome), as well as household poverty, caregiver quality of life and time use (secondary outcomes). Baseline data are being collected May-October 2023, with endline 24 months later. Analysis will be intention to treat. A complementary process evaluation will explore the implementation, acceptability of the programme, challenges and enablers to its delivery and mechanisms of impact. ETHICS AND DISSEMINATION: The study has received ethical approval from the London School of Hygiene and Tropical Medicine and the National Ethics Committee for Health Research in Laos. Informed consent and assent will be taken by trained data collectors. Data will be collected and stored on a secure, encrypted server and its use will follow a detailed data management plan. Findings will be disseminated in academic journals and in short briefs for policy and programmatic actors, and in online and in-person events. TRIAL REGISTRATION NUMBER: ISRCTN80603476.

"If he has education, there will not be any problem": Factors affecting access to education for children with disabilities in Tamil Nadu, India.

This study explores factors affecting children with disabilities' enrolment and experience in school in Tamil Nadu, India. In-depth interviews were conducted with 40 caregivers and 20 children with disabilities. Children were purposively selected to maximise heterogeneity by gender, impairment type and enrolment status, using data from a previous survey. Overall, caregivers recognised the importance of school for their children's future livelihoods or at least as a means of socialisation. However, some questioned the value of school, particularly for children with intellectual or sensory impairments. Other barriers to school enrolment and regular attendance included poor availability and affordability of transport, safety concerns or school staffs' concerns about children's behaviour being disruptive. While in school, many children's learning was limited by the lack of teacher training and resources for inclusive education. Poor physical accessibility of schools, as well as negative or overly protective attitudes from teachers and peers, often limited children's social inclusion while in school. These findings carry implications for the implementation of inclusive education in India and elsewhere, as they indicate that despite legislative progress, significant gaps in attendance, learning and social inclusion remain for children with disabilities, which may not be captured in traditional metrics on education access.