Rapid assessment of disability in the Philippines: understanding prevalence, well-being, and access to the community for people with disabilities to inform the W-DARE project.

BACKGROUND: International recognition that people with disabilities were excluded from the Millennium Development Goals has led to better inclusion of people with disabilities in the recently agreed Global Goals for Sustainable Development (SDGs) 2015-2030. Given the current global agenda for disability inclusion, it is crucial to increase the understanding of the situation of people with disabilities in the Philippines. The aim of this study was to estimate the prevalence of disability and compare the well-being and access to the community between people with and without disabilities. METHODS: A population-based survey was undertaken in District 2 of Quezon City and in Ligao City. 60 clusters of 50 people aged 18 years and older were selected with probability proportion to size sampling from both locations. The Rapid Assessment of Disability (RAD) survey was used to identify people with disabilities based on their responses to activity limitations. The levels of well-being and access to the community for people with disabilities were compared with controls matched by age, gender, and cluster. Information on barriers to accessing the community was also collected. RESULTS: The prevalence of disability was 6.8 (95 % CI: 5.9, 7.9) and 13.6 % (95 % CI: 11.4, 16.2) in Quezon City and Ligao City respectively. Psychological distress was the most commonly reported condition in both locations, although it was often reported with a co-morbid condition related to sensory, physical, cognitive, and communication difficulties. The prevalence of disability was associated with age and no schooling, but not associated with poverty. People with disabilities had significantly lower well-being scores and reduced access to health services, work, rehabilitation, education, government social welfare, and disaster management than people without disability. Having a disability and negative family attitudes were reported as barriers for people with disabilities participating in work, community meetings, religious activities, and social activities. CONCLUSIONS: The prevalence of disability among adults in District 2 of Quezon City and in Ligao City is higher than the estimated national prevalence of disability derived from the 2010 Philippines census. Disability is also associated with lower well-being and reduced participation across a number of domains of community life.

Prevalence and correlates of disability in Bogra district of Bangladesh using the rapid assessment of disability survey.

BACKGROUND: The aim of this study was to estimate the prevalence of disability and its associated risk factors among adults aged 18 years and over in Bogra district, Bangladesh. METHODS: The Rapid Assessment of Disability (RAD) survey was conducted using probability-proportional-to-size sampling to select 66 clusters each with 50 people aged 18 years and older in 2010. Households within clusters were selected through compact segment sampling. Disability was identified based on the responses to the self-assessment of functioning section of the RAD questionnaire. Descriptive and multivariate logistic regression analyses were performed to model the associations between risk factors and disability status. RESULTS: Of 1855 adults who participated in the study, 195 (10.5 %) had disability. Age and gender adjusted prevalence of disability in Bogra district was 8.9 % (95 % CI: 7.7, 10.3). The highest prevalence of functional limitation was related to psychological distress (4.7 %; 95 % CI: 3.8, 5.7) followed by vision (4.4 %; 95 % CI: 3.6, 5.4), and hearing (2.3 %; 95 % CI: 1.7, 3.0) difficulties. The adjusted odds of disability increased with age with approximately eight-fold increase from 2.9 % (95 % CI: 1.6, 5.1) in 18-24 years to 24.5 % (95 % CI: 20.2, 29.4) in 55 years and above. People with poor socio-economic status (OR 1.90; 95 % CI: 1.1, 3.3) and who were unemployed (OR = 4.6; 95 % CI: 1.8, 11.6) were more like to have disability compared to the higher socio-economic status and those who have an occupation respectively. CONCLUSIONS: There is a significant need for promoting programs for health, well-being, and rehabilitation, and policies specifically targeting the older population, women, unemployed and poor people in Bangladesh.

W-DARE: a three-year program of participatory action research to improve the sexual and reproductive health of women with disabilities in the Philippines.

BACKGROUND: In many contexts, women with disability have less access to sexual and reproductive health information, screening, prevention, and care services than women without disability. Women with disability are also known to be more likely to experience physical and sexual violence than women without disability. In the Philippines, health service providers often have little awareness of the sexual and reproductive experiences of women with disability and limited capacity to provide services in response to their needs. Very limited data are available to inform development of disability-inclusive sexual and reproductive health, and violence prevention and response, services in the country. This paper presents the protocol for W-DARE (Women with Disability taking Action on REproductive and sexual health), a three-year program of participatory action research that aims to improve the sexual and reproductive health of women with disability in the Philippines. DESIGN: W-DARE is a disability-inclusive program that will use mixed methods to 1) increase understanding of factors influencing the sexual and reproductive health of women with disability, and 2) develop, implement and evaluate local interventions to increase supply of and demand for services. W-DARE will generate data on the prevalence of disability in two districts; the wellbeing and community participation of people with and without disability, and identify barriers to community; and describe the sexual and reproductive health needs and experiences, and service-related experiences of women with disability. These data will inform the development and evaluation of interventions aiming to improve access to sexual and reproductive health services, and violence prevention and response services, for women with disability. Local women with disabilities, their representative organisations, and SRH service providers will be involved as members of the research team across all stages of the research. DISCUSSION: This three-year study will provide evidence about factors undermining the sexual and reproductive health of women with disability in a lower-middle income country, and provide new insights about what may be effective in increasing access to services in settings of limited resources. Findings will be relevant across Asia and the Pacific. Analysis of the program will also provide evidence about disability-inclusion in participatory action research approaches.

Field-testing of the rapid assessment of disability questionnaire.

BACKGROUND: The Rapid Assessment of Disability (RAD) questionnaire measures the magnitude and impact of disability and aims to inform the design of disability inclusive development programs. This paper reports the psychometric evaluation of the RAD. METHODS: The initial version of the RAD comprised five sections: 1) demographics, 2) functioning, 3) rights awareness, 4) well-being, and 5) access to the community. Item functioning and construct validity were assessed in a population-based study in Bangladesh. Data were analysed using descriptive statistics (sections 2 and 5) and Rasch modelling (sections 3 and 4). A subsequent case-control study in Fiji tested the refined questionnaire in a cross-cultural setting and assessed the sensitivity and specificity of the RAD section 2 to identify people with disability. RESULTS: 2,057 adults took part in the study (1,855 in Bangladesh and 202 in Fiji). The prevalence of disability estimated using RAD section 2 in Bangladesh was 10.5% (95% CI 8.8-12.2), with satisfactory sensitivity and specificity (62.4% and 81.2%, respectively). Section 3 exhibited multidimensionality and poor differentiation between levels of rights awareness in both Bangladesh (person separation index [PSI] = 0.71) and Fiji (PSI = 0.0), and was unable to distinguish between people with and without disability (Bangladesh p = 0.786, Fiji p = 0.43). This section was subsequently removed from the questionnaire pending re-development. Section 4 had good ability to differentiate between levels of well-being (PSI = 0.82). In both countries, people with disability had significantly worse well-being scores than people without disability (p < 0.001) and also access to all sectors of community except legal assistance, drinking water and toilets (p < 0.001). CONCLUSIONS: Filed-testing in Bangladesh and Fiji confirmed the psychometric robustness of functioning, well-being, and community access sections of the RAD. Information from the questionnaire can be used to inform and evaluate disability inclusive development programs.

Integration of rehabilitation services in primary, secondary, and tertiary levels of health care systems in low- and middle-income countries: a scoping review.

PURPOSE: Integration is a concept that seeks to strengthen the delivery of services to ensure people receive a continuum of care across the health system. We conducted a scoping review to explore how rehabilitation services have been integrated into health systems in low- and middle- income countries (LMICs). MATERIALS AND METHODS: We conducted a scoping review using Valentijn's Rainbow Model of Integrated Care (RMIC) as an organising framework. The key enablers of integration of rehabilitation were extracted, charted and summarised according to the RMIC framework. RESULTS: Of 4667 articles identified, 44 met inclusion criteria. Most studies focused on rehabilitation within secondary and tertiary level facilities, and described service models incorporating clinical, professional and functional integration characteristics. The geographical and clinical scope of rehabilitation models that demonstrate elements of integration from LMICs is limited. CONCLUSION: The key enablers identified highlight the important role of responsive multidisciplinary care plans, and interdisciplinary guidelines, protocols and interprofessional education to support an integrated rehabilitation service model in LMICs.

There is little published information about integrating rehabilitation into primary care in LMICs.Organizational integration of rehabilitation in LMIC health systems appears poor, at least in part due to dependence on non-state actors for service delivery.Multidisciplinary care plans, guidelines, protocols and interprofessional education are key enablers of integrated rehabilitation service models.Integration can be defined and strengthened but evidence about how collaboration and integration can be achieved in varied local contexts is lacking.

The Journey to Early Identification and Intervention for Children with Disabilities in Fiji.

Early identification of developmental delay or disability and access to early intervention improves outcomes for children with disabilities and their families. However, in many low- and middle-income countries, services and systems to enable timely, co-ordinated care and support are lacking. The aim of this research was to explore the experiences of families of children with developmental disabilities in Fiji in accessing services for intervention and support across sectors. This qualitative study involved conducting interviews with caregivers of children with disabilities (n = 12), and relevant key stakeholders from health, education, disability, and social support sectors (n = 17). We used journey maps to identify key stages of the families' journeys, identify key barriers and enablers at each stage, and provide multi-sectoral recommendations for each stage. Enablers include proactive help seeking behaviours, the use of informal support networks and an increasingly supportive policy environment. Barriers to identification include a lack of awareness of developmental disabilities and the benefits of early intervention among service providers and the community. A lack of service availability and capacity, workforce issues, family financial constraints and a lack of collaboration between sectors were barriers to intervention once needs were identified, resulting in significant unmet needs and impacting inclusion and participation for children with disabilities. Overcoming these challenges requires a multi-sectoral approach.

Rasch analysis reveals problems with multiplicative scoring in the macular disease quality of life questionnaire.

PURPOSE: To evaluate validity and psychometric characteristics of the Macular Disease Quality of Life questionnaire (MacDQoL), a multiplicative rating scale designed to measure vision-related quality of life (VRQoL) in macular diseases and age-related macular degeneration (AMD). DESIGN: Cross-sectional study. PARTICIPANTS: We included 108 patients with neovascular AMD at baseline before ranibizumab treatment. METHODS: The psychometric properties of the MacDQoL were assessed using Rasch analysis, exploring key indices such as response category functioning, instrument unidimensionality, discriminant ability, and targeting of item difficulty to patient ability. MAIN OUTCOME MEASURES: Measurement characteristics of the MacDQoL. RESULTS: In the MacDQoL's native form, the majority of response categories were underutilized and thresholds disordered. This could not be remedied without eliminating the importance ratings owing to the ambiguous nature of the response categories. Scaling problems were resolved by using the impairment rating scale only and collapsing response categories to 4. However, the MacDQoL was multidimensional, necessitating the omission of a number of items and splitting it into an activity limitation and mobility and a socioemotional well-being scale. This improved the psychometric parameters of the revised MacDQoL, although no correlation with clinical measures such as visual acuity was found. CONCLUSIONS: The multiplicative rating scale of the MacDQoL is flawed and does not provide scientific measurement of VRQoL. Measurement can be restored with a series of revisions to the instrument. This study reinforces the importance of considering rating scale design when choosing patient reported outcomes instruments for healthcare research.

Barriers to access to ear and hearing care services in low- and middle- income countries: A scoping review.

People living in low- and middle- income countries (LMICs) meet significant challenges in accessing ear and hearing care (EHC) services. We conducted a scoping review to identify and summarise such barriers, to recognise gaps in the literature, and to identify potential solutions. Reviewers independently screened titles, abstracts and full-text articles and charted data. We undertook thematic analysis of supply and demand side dimensions of access, and summarised findings mapped against the Levesque framework. Of 3048 articles screened, 62 met inclusion criteria for review. Across the five access dimensions, supply-side constraints were more frequently described, the most common being a shortage of EHC workforce or appropriate facilities, despite high demand. We identified a thin geographical spread of literature on barriers to accessing EHC services in LMICs, reflecting low availability of such services. LMICs face a diverse range of demand and supply side challenges including workforce, equipment and resource shortages, and challenges for the majority of the population to pay for such services. There is a need for many LMICs to develop health policy and programmes in EHC, including integration into primary care, scaling up the EHC workforce through increased training and education, and improving EHC literacy through public health measures.

The Future of Disability Research in Australia: Protocol for a Multiphase Research Agenda-Setting Study.

BACKGROUND: For people with disabilities to live a good life, it is essential that funded research in health and social care addresses their interests, meets their needs, and fills gaps in our understanding of the impact that services, systems, and policies may have on them. Decisions about research funding should be based on an understanding of the research priorities of people with disabilities, their supporters and allies, disability researchers, service providers, and policy makers working in the field. OBJECTIVE: The aim of this protocol is to describe the research design and methods of a large-scale, disability research agenda-setting exercise conducted in 2021 in Australia. METHODS: The research agenda-setting exercise involves 3 integrated phases of work. In the first phase, a previous audit of disability research in Australia is updated to understand previous research and continuing gaps in the research. Building on this, the second phase involves consultation with stakeholders-people with disabilities and their supporters and family members, the disability workforce, and people working within services and connected sectors (eg, aging, employment, education, and housing), academia, and public policy. Data for the second phase will be gathered as follows: a national web-based survey; a consultation process undertaken through the government and nongovernment sector; and targeted consultation with Aboriginal and Torres Strait Islander people, children with disabilities and their families, people with cognitive disability, and people with complex communication needs. The third phase involves a web-based survey to develop a research agenda based on the outcomes of all phases. RESULTS: We have started working on 2 parts of the research prioritization exercise. Through the research-mapping exercise we identified 1241 journal articles and book chapters (referred to as research papers) and 225 publicly available reports (referred to as research reports) produced over the 2018-2020 period. Data collection for the national survey has also been completed. We received 973 fully completed responses to the survey. Analysis of these data is currently underway. CONCLUSIONS: This multi-method research agenda-setting study will be the first to provide an indication of the areas of health and social research that people across the Australian disability community consider should be prioritized in disability research funding decisions. Project results from all phases will be made publicly available through reports, open-access journal publications, and Easy Read documents. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31126.

The relative impact of vision impairment and cardiovascular disease on quality of life: the example of pseudoxanthoma elasticum.

OBJECTIVE: To investigate the impact of pseudoxanthoma elasticum (PXE), a rare hereditary disease of concurrent vision impairment (VI) and cardiovascular complications (CVCs), on vision-related (VRQoL) and health-related quality of life (HRQoL). METHODS: VRQoL and HRQoL were assessed using the Impact of Vision Impairment (IVI) questionnaire and the Short Form Health Survey (SF-36) in 107 PXE patients. Patients were stratified into four groups: A = no VI or CVC; B = CVCs only; C = VI only; and D = both VI and CVCs. RESULTS: Following Rasch analysis, the IVI was found to function as a vision-specific functioning and emotional well-being subscale, and the SF-36 as a health-related physical functioning and mental health subscale. The presence of VI and CVC were significant predictors of vision-specific functioning and emotional well-being (p < 0.001), with a clinically meaningful decrement in vision-specific functioning in patients with VI. No associations were found for the SF-36 Physical Functioning and Mental Health scores between any groups. CONCLUSIONS: Vision impaired patients with PXE report significantly poorer vision-specific functioning than PXE patients without VI. In contrast, the relative impact of PXE on reported general HRQoL was much less. Our results suggest that vision impairment has the larger impact on QoL in this sample.

The impact of the severity of vision loss on vision-specific functioning in a German outpatient population - an observational study.

BACKGROUND: To validate the German-translated VF-14, a vision-specific scale, and determine the relationship between the severity of vision impairment, ocular conditions, and visual functioning. METHODS: This was a clinic-based, cross-sectional study with 184 patients with low vision and 90 normal-sighted controls recruited from a German eye hospital. Participants underwent a clinical examination and completed the German VF-14 scale. The validity of the VF-14 scale was assessed using Rasch analysis. The main outcome measure was the visual functioning overall score. RESULTS: The participants' mean ± SD [standard deviation] age was 59.4 ± 21.8 years ,and there were more female (58.4%) than male participants. The main cause of vision loss was age-related macular degeneration [AMD] (n = 54, 19.7%). Rasch analysis substantiated the German VF-14 to be a valid scale to assess visual functioning in the sample. Visual functioning consistently declined with worsening vision. In adjusted-multivariate analysis models, compared to control participants, those with mild, or moderate/severe vision impairment recorded significantly poorer visual functioning scores (p < 0.05). The independent association was clinically significant for those with moderate/severe vision impairment. The main ocular conditions were also found to be independently associated with worse visual functioning, with clinical significance found for AMD, diabetic retinopathy, and other retinal diseases. CONCLUSIONS: Using a psychometrically valid German-translated VF-14, even mild vision impairment was independently associated with poor visual functioning. These findings reinforce the importance of early preventative and rehabilitative efforts to prevent longitudinal deterioration in vision loss.

Combining Child Functioning Data with Learning and Support Needs Data to Create Disability-Identification Algorithms in Fiji's Education Management Information System.

Disability disaggregation of Fiji's Education Management Information System (FEMIS) is required to determine eligibility for inclusive education grants. Data from the UNICEF/Washington Group Child Functioning Module (CFM) alone is not accurate enough to identify disabilities for this purpose. This study explores whether combining activity and participation data from the CFM with data on environmental factors specific to learning and support needs (LSN) more accurately identifies children with disabilities. A survey on questions related to children's LSN (personal assistance, adaptations to learning, or assessment and assistive technology) was administered to teachers within a broader diagnostic accuracy study. Descriptive statistics and correlations were used to analyze relationships between functioning and LSN. While CFM data are useful in distinguishing between disability domains, LSN data are useful in strengthening the accuracy of disability severity data and, crucially, in identifying which children have disability amongst those reported as having some difficulty on the CFM. Combining activity and participation data from the CFM with environmental factors data through algorithms may increase the accuracy of domain-specific disability identification. Amongst children reported as having some difficulty on the CFM, those with disabilities are effectively identified through the addition of LSN data.

Development of a Digital Case Management Tool for Community Based Inclusive Development Program.

Disability inclusive development practices require reliable data to identify people with disabilities, their barriers to participation and support needs. Although several tools are available for measuring different components of disability, it is often difficult for program teams in low resource settings, including lay community workers of community based inclusive development (CBID) programs, to collect and analyze data for program monitoring and evaluation. This paper presents the development of a digital CBID Modular Tool with automated data analysis to support routine case management processes and monitoring of a CBID program in Laos PDR. The tool was developed in different phases involving stakeholder consultations, auditing of existing tools, content development for the different modules for disability assessment and support needs, software development and testing. The tool was developed in a participatory process including people with disabilities. The tool measures needs and support requirements of people with disabilities in health, functioning, economic, education and caregiver support domains, and enables intervention planning. The content included is both context specific and universal as derived from the widely used validated tools. This unique digital CBID Modular Tool can support data collection by lay community workers and support reliable data collection to measure disability inclusion in a development program.

Depression training program for eye health and rehabilitation professionals.

PURPOSE: Depression often remains undetected in people with vision impairment. This study aimed to determine the effectiveness of a depression training program on practitioners' confidence, perceived barriers, and their likelihood of responding to depression in patients with vision impairment. METHODS: This study was a pre and post single group evaluation involving 36 eye health and rehabilitation practitioners. Three 1.5-h group training sessions were held once a week for 3 consecutive weeks. The modules covered (1) understanding depression, (2) detecting depressive symptoms, and (3) developing and implementing referral pathways. Three main outcome measures were assessed: confidence in working with patients who may be depressed; perceived barriers to the recognition and management of depression; and likelihood of responding to depression. RESULTS: The training significantly improved practitioners' confidence and reduced perceived barriers to managing depression (p < 0.001). After training, participants were significantly more likely to respond to depression in their patients (p < 0.001). CONCLUSIONS: This preliminary study found that a brief training program is effective in increasing practitioners' ability to respond to depression in patients with vision impairment. Further work is required to determine whether these effects are sustained over time and result in improved recognition and management of depression in people with vision impairment.

Is the pediatric quality of life inventory valid for use in preschool children with refractive errors?

PURPOSE: To determine the psychometric validity of the pediatric quality of life inventory (PedsQL 4.0) in assessing the impact of refractive errors on health-related quality of life (HRQoL) in preschool children in Singapore. METHODS: Parents of toddlers (aged 25 to 48 months) and young children (49 to 72 months) completed the PedsQL 4.0, an HRQoL scale as part of population-based trial in Singapore. The outcome measures were the overall score, and the "physical"; "emotional"; "social"; and "school" functioning subscales. Rasch analysis was used to validate the PedsQL 4.0. RESULTS: Parents of 939 (48.9%) toddlers and 982 (51.1%) young children completed the PedsQL 4.0 survey. The overall mean (±standard deviation) spherical equivalence for the right eye was 0.47 ± 1.13 diopter (D) for toddlers and 0.74 ± 1.22 D for young children. One hundred forty-nine (15.9%) toddlers and 90 (9.2%) young children were considered myopic (≥-0.50 D). Most participants (n = 1286, 89.6%) had presenting visual acuity 6/9 or better. Rasch analysis showed evidence of disordered category thresholds and poor person-item targeting for both groups. The separation reliability was 0.00 for toddlers and 0.03 for young children, indicating there was no variance in both samples. The PedsQL 4.0 overall and subscale scores displayed substantial multidimensionality as the variance values explained by the measures was <25% in both groups. A minimum value of 60% is usually considering acceptable. CONCLUSIONS: The PedsQL 4.0 in its current state is not a valid psychometric scale to effectively evaluate the impact of refractive errors on HRQoL in preschool children in Singapore.

Vision impairment and refractive errors in refugees presenting to community optometry clinics in Victoria, Australia.

BACKGROUND: There is a paucity of data relating to refugee eye health in Australia. This study aimed at investigating the spectrum of vision impairment and other ocular conditions in refugees utilising the Victorian Eyecare Service operated by the Australian College of Optometry. METHODS: A cross-sectional study of electronic clinical records of 518 individuals (adults and children) recognised as refugees by the Australian College of Optometry and treated between January 2013 and May 2014 were identified. Extracted data included presenting visual acuities, best-corrected visual acuities, and final refraction values (using spherical equivalents), for both eyes. Diagnoses of presenting ocular conditions were also extracted. RESULTS: Of all refugees examined, 129 (27.2 per cent) had some degree of vision impairment (≤ 6/9.5) based on presenting visual acuities in their better eye; five (1.0 per cent) being of a severe (≤ 6/60) or profound (≤ 6/120) nature. In contrast, 27 (6.3 per cent) refugees had some degree of vision impairment based on best-corrected visual acuities in their better eye; two (0.4 per cent) being of a severe or profound nature. The prevalence of myopia (≥ -0.50 D) in the better eye was 23.0 per cent (n = 114); 25 (5.0 per cent) being moderate (≥ -3.00 D) to high (≥ -6.00 D). The prevalence of hypermetropia (≥ +2.00 D) in the better eye was 3.2 per cent (n = 16); 12 (2.4 per cent) being moderate (≥ +2.25 D) to high (≥ +5.25 D). The most common ocular conditions diagnosed at initial presentation were refractive error (n = 104, 20.1 per cent) and dry eyes (n = 57, 11.0 per cent). CONCLUSION: Mild vision impairment and refractive error are significant issues for refugees attending the Australian College of Optometry, emphasising the need for optometry, particularly refractive, services in this population.

Validation of the visual disability questionnaire (VDQ) in India.

PURPOSE: To validate visual disability questionnaire (VDQ) in patients with low vision in India, and explore whether the two latent traits "importance" and "difficulty" associated with performance of daily activities are valid and independent constructs. METHODS: The VDQ consisting of 25 items was administered verbally to 137 subjects with low vision aged 16 to 89 years. Responses for each item were rated for importance and difficulty using a 5-category Likert scale. Rasch analysis was used to estimate interval measures of response ratings. RESULTS: Subjects could discriminate only three response categories for importance and difficulty. Content validity was demonstrated by good separation indices for importance (4.24 and 2.59 for the item and person parameters, respectively) and difficulty ratings (7.64 and 3.33, respectively). High reliability scores were recorded for importance (0.95 and 0.87) and difficulty ratings (0.98 and 0.92). The most important items were "grooming" (1.15 logits) and "reading newspaper" (0.97 logits). Although "threading a needle" was the least important item (-2.79 logits), it was the most difficult task (3.13 logits). The least difficult item was moving around in familiar places (-2.51 logits). A poor correlation was observed between the item measures (r = -0.19, p = 0.34) and also between person measures (r = 0.18, p = 0.03) of importance and difficulty. CONCLUSIONS: The VDQ is a valid questionnaire with importance and difficulty ratings found to be independent constructs. This questionnaire could be used to prioritize the goals for rehabilitation intervention in patients with low vision.

The UNICEF/Washington Group Child Functioning Module-Accuracy, Inter-Rater Reliability and Cut-Off Level for Disability Disaggregation of Fiji's Education Management Information System.

This paper explores the validity (sensitivity and specificity) of different cut-off levels of the UNICEF/Washington Group Child Functioning Module (CFM) and the inter-rater reliability between teachers and parents as proxy respondents, for disaggregating Fiji's education management information system (EMIS) by disability. The method used was a cross-sectional diagnostic accuracy study comparing CFM items to standard clinical assessments for 472 primary school aged students in Fiji. Whilst previous domain-specific results showed "good" to "excellent" accuracy of the CFM domains seeing, hearing, walking and speaking, newer analysis shows only "fair" to "poor" accuracy of the cognitive domains (learning, remembering and focusing attention) and "fair" of the overall CFM (area under the Receiver Operating Characteristic curve: 0.763 parent responses, 0.786 teacher responses). Severe impairments are reported relatively evenly across CFM response categories "some difficulty", "a lot of difficulty" and "cannot do at all". Most moderate impairments are reported as "some difficulty". The CFM provides a core component of data required for disaggregating Fiji's EMIS by disability. However, choice of cut-off level and mixture of impairment severity reported across response categories are challenges. The CFM alone is not accurate enough to determine funding eligibility. For identifying children with disabilities, the CFM should be part of a broader data collection including learning and support needs data and undertaking eligibility verification visits.

Validating the UNICEF/Washington Group Child Functioning Module for Fijian schools to identify seeing, hearing and walking difficulties.

PURPOSE: This study investigated the seeing, hearing and walking questions of the UNICEF/Washington Group Child Functioning Module and the inter-rater reliability between teachers and parents as proxy respondents. METHODS: Cross-sectional diagnostic accuracy study, two-gate design with representative sampling, comparing Module responses to reference standard assessments for 472 primary aged students in Fiji. Receiver operating characteristic curves were constructed to determine the area under the curve and optimal cut-off points. RESULTS: Areas under the curves ranged from 0.823 to 0.889 indicating "good" diagnostic accuracy. Inter-rater reliability between parent and teacher responses was "good" to "excellent". The optimal cut-off determined by the Youden Index was "some difficulty" however a wide spread of impairment levels were found in this category with most children either having none or substantial impairments. CONCLUSIONS: The diagnostic accuracy of the Module seeing, hearing and walking questions appears acceptable with either parents or teachers as proxy respondents. For education systems, use of the cut-off "some difficulty" with accompanying clinical assessment may be important to capture children who require services and learning supports and avoid potentially misleading categorization. Given the high proportion of the sample from special schools research is required to further test the Module in mainstream schools. Implications for rehabilitation Identification of children who are at risk of disability in Fiji is important to enable planning, monitoring and evaluating access to quality inclusive education. The UNICEF/Washington Group Child Functioning Module appears to be a practical and effective tool that can be used by teachers to identify children at risk of disability. Children identified on the UNICEF/Washington Group Child Functioning Module as having "some difficulty" or higher levels of difficulty in relation to vision, hearing or walking should be referred for further assessment and services. Rehabilitation services in Fiji need to prepare for greater numbers of referrals as the Ministry of Education increasingly rolls out the inclusive education policy, which includes identification by schools of children at risk of disability.

Measurement accuracy: Enabling human rights for Fijian students with speech difficulties.

PURPOSE: The Universal Declaration of Human Rights enshrines the rights to communication and education and measuring access to these rights for children with disabilities is fundamental. The UNICEF/Washington Group Child Functioning Module (CFM) is being promoted to measure progress against the Sustainable Development Goals for children with disabilities. This cross-sectional diagnostic accuracy study in Fiji compares parent and teacher CFM responses to the Intelligibility in Context Scale for 463 primary-aged students with and without speech difficulties. METHOD: Receiver operating characteristic curves were constructed to analyse CFM accuracy and determine optimal cut-off points; inter-rater reliability between teachers and parents was calculated. RESULT: Parent responses to the CFM speech questions achieved an area under the curve of 0.98, indicating "excellent" diagnostic accuracy. Teachers achieved 0.92 ("very good"). The Youden Index identified the optimal cut-off as "some difficulty". CONCLUSION: The CFM appears effective when used by parents or teachers for distinguishing between children with and without speech difficulties. While identified as the optimal cut-off statistically, the "some difficulty" category identifies too many children without speech difficulties to be simplistically applied to funding eligibility. The CFM should be used as a screening tool, followed by further assessment to confirm eligibility.