Renegotiating dimensions of the self: A systematic review and qualitative evidence synthesis of the lived experience of self-managing rheumatoid arthritis.

BACKGROUND: As chronic illnesses, such as rheumatoid arthritis (RA), place an increased burden on health-care systems, the ability of individuals to self-manage these diseases is crucial. OBJECTIVE: To identify and synthesize the lived experience of self-management described by adults living with RA. DESIGN: A systematic search of five electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO and ASSIA) was undertaken to identify relevant studies. Data were extracted and quality-assessed using CASP guidelines. A meta-synthesis was conducted based on Thomas and Harden's thematic synthesis approach. RESULTS: The search identified 8423 publications. After removing duplicates, 6527 records remained of which 32 studies met the inclusion criteria. Quality of studies was moderate to high, yet a considerable lack of reflection on researcher bias was evident. Our analysis identified 28 dimensions of self-management RA across six domains: (a) cognitive-emotional, (b) behavioural, (c) social, (d) environmental, (e) physical and (f) technological. Cognitive-emotional experiences dominated the analysis. Renegotiating 'the self' (self-concept, self-esteem, self-efficacy) was a key focus of self-management among individuals with RA. CONCLUSION: Our findings highlight the focus of 'the self' as a central concern in the self-management of RA. Standardized self-management programmes may primarily focus on disease management and daily functioning. However, we suggest that personal biographies and circumstances should move to the fore of self-management support. REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews 2018: CRD42018100450. PATIENT OR PUBLIC CONTRIBUTION: Patient and public involvement was not explicit in this review. However, three authors provided a patient perspective on the self-management of arthritis and autoimmune disease.

Using geographic information systems to map older people's emergency department attendance for future health planning.

OBJECTIVES: This study aimed to assess the pattern of use of EDs, factors contributing to the visits, geographical distribution and outcomes in people aged 65 years or older to a large hospital in Dublin. METHODS: A retrospective analysis of 2 years of data from an urban university teaching hospital ED in the southern part of Dublin was reviewed for the period 2014-2015 (n=103 022) to capture the records of attenders. All ED presentations by individuals 65 years and older were extracted for analysis. Address-matched records were analysed using QGIS, a geographic information systems (GIS) analysis and visualisation tool to determine straight-line distances travelled to the ED by age. RESULTS: Of the 49 538 non-duplicate presentations in the main database, 49.9% of the total are women and 49.1% are men. A subset comprised of 40 801 had address-matched records. When mapped, the data showed a distinct clustering of addresses around the hospital site but this clustering shows different patterns based on age cohort. Average distances travelled to ED are shorter for people 65 and older compared with younger patients. Average distances travelled for those aged 65-74 was 21 km (n=4177 presentations); for the age group 75-84, 18 km (n=2518 presentations) and 13 km for those aged 85 and older (n=2104 presentations). This is validated by statistical tests on the clustered data. Self-referral rates of about 60% were recorded for each age group, although this varied slightly, not significantly, with age. CONCLUSIONS: Health planning at a regional level should account for the significant number of older patients attending EDs. The use of GIS for health planning in particular can assist hospitals to improve their understanding of the origin of the cohort of older ED patients.

A study of human resource competencies required to implement community rehabilitation in less resourced settings.

BACKGROUND: It is estimated that over one billion persons worldwide have some form of disability. However, there is lack of knowledge and prioritisation of how to serve the needs and provide opportunities for people with disabilities. The community-based rehabilitation (CBR) guidelines, with sufficient and sustained support, can assist in providing access to rehabilitation services, especially in less resourced settings with low resources for rehabilitation. In line with strengthening the implementation of the health-related CBR guidelines, this study aimed to determine what workforce characteristics at the community level enable quality rehabilitation services, with a focus primarily on less resourced settings. METHODOLOGY: This was a two-phase review study using (1) a relevant literature review informed by realist synthesis methodology and (2) Delphi survey of the opinions of relevant stakeholders regarding the findings of the review. It focused on individuals (health professionals, lay health workers, community rehabilitation workers) providing services for persons with disabilities in less resourced settings. RESULTS: Thirty-three articles were included in this review. Three Delphi iterations with 19 participants were completed. Taken together, these produced 33 recommendations for developing health-related rehabilitation services. Several general principles for configuring the community rehabilitation workforce emerged: community-based initiatives can allow services to reach more vulnerable populations; the need for supportive and structured supervision at the facility level; core skills likely include case management, social protection, monitoring and record keeping, counselling skills and mechanisms for referral; community ownership; training in CBR matrix and advocacy; a tiered/teamwork system of service delivery; and training should take a rights-based approach, include practical components, and involve persons with disabilities in the delivery and planning. CONCLUSION: This research can contribute to implementing the WHO guidelines on the interaction between the health sector and CBR, particularly in the context of the Framework for Action for Strengthening Health Systems, in which human resources is one of six components. Realist syntheses can provide policy makers with detailed and practical information regarding complex health interventions, which may be valuable when planning and implementing programmes.

Promoting good policy for leadership and governance of health related rehabilitation: a realist synthesis.

BACKGROUND: Good governance may result in strengthened performance of a health system. Coherent policies are essential for good health system governance. The overall aim of this research is to provide the best available scientific evidence on principles of good policy related leadership and governance of health related rehabilitation services in less resourced settings. This research was also conducted to support development of the World Health Organization's (WHO) Guidelines on health related rehabilitation. METHODS: An innovative study design was used, comprising two methods: a systematic search and realist synthesis of literature, and a Delphi survey of expert stakeholders to refine and triangulate findings from the realist synthesis. In accordance with Pawson and Tilley's approach to realist synthesis, we identified context mechanism outcome pattern configurations (CMOCs) from the literature. Subsequently, these CMOCs were developed into statements for the Delphi survey, whereby 18 expert stakeholders refined these statements to achieve consensus on recommendations for policy related governance of health related rehabilitation. RESULTS: Several broad principles emerged throughout formulation of recommendations: participation of persons with disabilities in policy processes to improve programme responsiveness, efficiency, effectiveness, and sustainability, and to strengthen service-user self-determination and satisfaction; collection of disaggregated disability statistics to support political momentum, decision-making of policymakers, evaluation, accountability, and equitable allocation of resources; explicit promotion in policies of access to services for all subgroups of persons with disabilities and service-users to support equitable and accessible services; robust inter-sectoral coordination to cultivate coherent mandates across governmental departments regarding service provision; and 'institutionalizing' programmes by aligning them with preexisting Ministerial models of healthcare to support programme sustainability. CONCLUSIONS: Alongside national policymakers, our policy recommendations are relevant for several stakeholders, including service providers and service-users. This research aims to provide broad policy recommendations, rather than a strict formula, in acknowledgement of contextual diversity and complexity. Accordingly, our study proposes general principles regarding optimal policy related governance of health related rehabilitation in less resourced settings, which may be valuable across diverse health systems and contexts.

Family voices: life for family carers of people with intellectual disabilities in Ireland.

BACKGROUND: Families in Ireland remain the main providers of support for people with Intellectual disabilities, and the aim of this study was to map their life experiences whilst involving their family members as co-researchers. MATERIALS AND METHOD: This qualitative, participatory study involved 10 focus groups attended by 70 parents and siblings of people with intellectual disabilities. Data were analysed using thematic analysis. RESULTS: Caring for a family member with intellectual disabilities was found to be a dynamic and adaptive process. The well-being of the family and the challenges they face throughout their lives was the central theme identified. This was affected by: the availability of appropriate supports for families and having to advocate for them, communication and relationships with services and professionals, the availability of information and attitudes towards disability and governmental support. CONCLUSIONS: Strategies are suggested as to how services can better support family carers in Ireland in their role. These include families being provided with flexible and timely support for families at critical times; being offered services, support, entitlements and information without having to fight for them; knowing that their family member with intellectual disabilities is well cared for, listened to and provided with opportunities to develop and be part of the community; and carers being shown respect, listened to and involved in decisions.

Assistive technology: The current perspective in India.

The world, today, recognizes the increasing importance of assistive technology (AT) that can reduce the functional limitations of persons with disabilities, individuals with chronic debilitating diseases, and elders. This indicates that at some point, everyone, either temporary or permanent, will require AT to improve their physical and functional abilities, thus contributing to independent living, social inclusion, and education. Besides this, the need for AT will be growing with a majority from low-middle-income countries. The same is true for India though we are not sure how many people have met a need, and unmet need for AT to date, but the requirement will continue to increase. There is a significant gap between needs and access to AT. Recently, the WHO has led many initiatives related to AT services after the 71st World Health Assembly's resolution in 2018, to improve access to AT for its member states. The UN Sustainable Development Goals (SDGs) have pledged that no one should be left behind irrespective of personal characteristics. India, a ratified member state, needs to align with various initiatives undertaken by the WHO and the UN. Despite many challenges, India needs to formulate evidence-based AT policy, planning within the purview of the healthcare delivery system in collaboration with various government and nongovernment sectors, including industries. This article explores the need, access, and potential challenges associated with AT services in India. Finally, we discussed various initiatives on AT in the country and possible recommendations to improve AT services across.

Inclusive health.

We propose the concept of Inclusive Health to encapsulate the Health for All ethos; to build on the rights-based approach to health; to promote the idea of inclusion as a verb, where a more proactive approach to addressing distinctive and different barriers to inclusion is needed; and to recognise that new initiatives in human resources for health can offer exciting and innovative ways of healthcare delivery. While Inclusive Education has become a widely recognised and accepted concept, Health for All is still contested, and new thinking is required to develop its agenda in line with contemporary developments. Inclusive Health refers both to who gets health care and to who provides it; and its ethos resonates strongly with Jefferson's assertion that 'there is nothing more unequal, than the equal treatment of unequal people'. We situate the timeliness of the Inclusive Health concept with reference to recent developments in the recognition of the rights of people with disability, in the new guidelines for community-based rehabilitation and in the World Report on Disability. These developments offer a more inclusive approach to health and, more broadly, its inter-connected aspects of wellbeing. A concept which more proactively integrates United Nations conventions that recognise the importance of difference - disability, ethnicity, gender, children - could be of benefit for global healthcare policy and practice.

A systematic review of the effectiveness of alternative cadres in community based rehabilitation.

BACKGROUND: The Millennium Development Goals (MDGs) aim to improve population health and the quality and dignity of people's lives, but their achievement is constrained by the crisis in human resources for health. An important potential contribution towards achieving the MDGs for persons with disabilities will be the newly developed Guidelines for Community Based Rehabilitation (CBR), launched in 2010. Given the global shortage of medical and nursing personnel and highly skilled rehabilitation practitioners, effective implementation of the CBR guidelines will require additional health workers, with improved distribution and a new skill set, allowing them to work across the health, education, livelihoods, social, and development sectors. METHODS: We conducted a systematic review to evaluate existing evidence regarding the effectiveness of alternative cadres working in CBR in low and middle income countries. We searched the following databases: PUBMED, LILACS, SCIE, ISMEAR, WHOLIS, AFRICAN MED IND. We also searched the online archive of the Asia Pacific Disability Rehabilitation Journal (available from 2002 to 2010), which was not covered by any of the other databases. There was no limit set on inclusion with regard to how recent a publication was in the general search. RESULTS: The search yielded 235 abstracts, only 6 of which addressed CBR through some type of evaluative component. Three of the studies explored the effects of CBR interventions, mainly related to physical disabilities, while three explored issues concerned with the work performance of rehabilitation workers. Altogether the studies covered four different countries. CONCLUSION: All six studies related to specific service delivery in local contexts, using outcome measures that were not comparable across studies. We do not, therefore, feel that the current results provide adequate methodology or evidence for reliably generalizing their results. Due to the dearth of evidence regarding the effectiveness of alternative cadres in CBR, systematic research is needed on the training, performance and impacts of rehabilitation workers, including their capability of working across sectors and engaging with and making use of health systems research.

Ecosystems Determinants of Nutritional Adequacy Among the Indian Preschool Children.

Given the specified importance of dietary diversity in reducing the burden of malnutrition, our study explores the reasons for the high rate of malnutrition in India through assessment of a comprehensive range of ecosystem factors leading to poor nutrients intake. The study uses the Dietary Diversity Score (DDS) to investigate preschoolers, through differences in wealth, gender, and health. Demographic and Health Survey (2015-16) data of 1,40,470 preschool children between the ages of 2-5 years, is investigated using the Bronfenbrenner's Ecological Systems Theory. Multiple linear regression models developed to investigate the association between variables, depict the importance of vaccination (p-value < 0.01, 95% CI 0.02-0.06) as positively impacting the outcome measures. Interestingly, overall wealth index does not impact the dietary diversity of the child. The lower wealth index, however, significantly impacts the DDS of the female child as compared to the male child (p-value < 0.1, 95% CI - 0.03 to 0.02), indicating that the lower wealth index plays a role in developing the non-egalitarian gender attitudes for female children. Policy implications involve adapting biofortified foods with higher density of nutrients with major focus on female children to minimize the gender gap and leveraging the digital technology such as telemedicine, and advanced techniques such as artificial intelligence, machine learning, and big data to offer real-time surveillance to address the healthcare needs in the ongoing immunization programs. Supplementary Information: The online version contains supplementary material available at 10.1007/s41745-022-00339-4.

Correction: (In)Visible illness: A photovoice study of the lived experience of self-managing rheumatoid arthritis.

[This corrects the article DOI: 10.1371/journal.pone.0248151.].

(In)Visible illness: A photovoice study of the lived experience of self-managing rheumatoid arthritis.

BACKGROUND: Chronic illnesses, such as Rheumatoid Arthritis (RA), are a growing burden on health care systems worldwide. Self-management emphasises the patient's central role in managing their illness. This is pertinent given the majority of care is provided by the individual themselves; yet how individuals make sense of self-management in everyday life is largely unseen. OBJECTIVE: The purpose of this study was to capture the strengths and concerns of individuals with RA in self-managing their illness, raise awareness of their lived experience and spark a dialogue among stakeholders. METHODS: A community-based participatory approach, Photovoice, was adopted. A purposive sample of participants were tasked with taking photographs to represent the challenges and solutions to living with RA. Group workshops and semi-structured interviews were conducted to facilitate reflection, dialogue and analysis. Data analysis followed Braun and Clarke's thematic analysis. Public exhibitions were held throughout the Autumn of 2019. RESULTS: Eight women and three men (n = 11) across suburban and urban regions of Ireland were recruited (mean age 57 years, disease duration 4-21 years). Participants identified four main themes which reflected the lived experience of self-managing RA: (i) I'm Here but I'm Not, (ii) Visible Illness, (iii) Medicine in All its Forms, (iv) Mind Yourself. These themes captured the challenge of reduced agency, limited contribution and participation, and a complex relationship between visible and invisible illness. Solutions focused on improving psychological and emotional resilience, particularly through personal reflection and increased agency. CONCLUSIONS: Our findings suggest that RA is experienced as a fluid relationship between states of masking and surfacing of illness shaped by contextual and situational factors. Photovoice was a highly effective tool to capture and communicate this complexity. Supporting increased agency among individuals with RA to control the (in)visibility of illness and disability can inform the development of future self-management support.

Adapting health interventions for local fit when scaling-up: a realist review protocol.

INTRODUCTION: Scaling-up is essential to ensure universal access of effective health interventions. Scaling-up is a complex process, which occurs across diverse systems and contexts with no one-size-fits-all approach. To date, little attention has been paid to the process of scaling-up in how to make adaptations for local fit. The aim of this research is to develop theory on what actions can be used to make adaptations to health interventions for local fit when scaling-up across diverse contexts that will have practical application for implementers involved in scaling-up. METHODS AND ANALYSIS: Given the complexity of this subject, a realist review methodology was selected. Specifically, realist review emphasises an iterative, non-linear process, whereby the review is refined as it progresses. The identification of how the context may activate mechanisms to achieve outcomes is used to generate theories on what works for whom in what circumstances. This protocol will describe the first completed stage of development of an initial programme theory framework, which identified potential actions, contexts, mechanisms and outcomes that could be used to make adaptations when scaling-up. It will then outline the methods for future stages of the review which will focus on identifying case examples of scale-up and adaptation in practice. This realist review consists of six stages: (i) clarifying scope and development of a theoretical framework, (ii) developing a search strategy, (iii) selection and appraisal, (iv) data extraction, (v) data synthesis and analysis and (vi) further theory refinement with stakeholders. ETHICS AND DISSEMINATION: This review will develop theory on how adaptations can be made when scaling-up. Findings will be disseminated in a peer-reviewed journal and through stakeholder engagement as part of the research process. Ethical approval has been received through Health Policy and Management/Centre for Global Health Research Ethics Committee of Trinity College Dublin.

"This one will delay us": barriers to accessing health care services among persons with disabilities in Malawi.

PURPOSE: This paper explores the barriers which people with disabilities experience in accessing health care services in Malawi. METHODOLOGY: Fifty-two in-depth interviews were conducted with people with various types of disabilities. These interviews were conducted in four districts in Malawi: Blantyre and Phalombe in the Southern Region; Ntchisi in the Central Region, and Rumphi in the North. A team of trained research assistants conducted the interviews. RESULTS: The major challenges that people with disabilities experience include the cost of accessing health care, long distances to health facilities, lack of transport, hilly terrains and flooding of rivers during the rainy season, communication challenges with the health providers and poor attitude of health workers. Some of these challenges are not unique to people with disabilities, but constitute more of a problem among people with disabilities. CONCLUSION: There is a need to address these challenges through the expansion of the provision of assistive devices, implementing comprehensive outreach services targeting people with disabilities and strengthening the links between key component of access to quality health care. Attitudinal barriers and lack of resources remain major challenges. Implications for rehabilitation Though people with disabilities face challenges accessing health care world-wide, the challenges are greater in low-income countries. The current study in Malawi confirms this. Major challenges include costs of care, transport costs, and inaccessible facilities. Lack of health worker awareness and attitudinal barriers are major issues of concern. It is imperative, given this situation, that effort is spent in Malawi and similar contexts on dealing with issues of stigma and discrimination especially in the health care sector. It is also important to explore cost-effective ways of assisting people with disabilities accessing appropriate transport, which should be seen as part of the healthcare system. Though the cost of providing equitable care may be high in low-income contexts, this is a human right. Training and creating an accessible and disability-friendly service environment is a key priority.

Predictors of Utilisation of Skilled Maternal Healthcare in Lilongwe District, Malawi.

BACKGROUND: Despite numerous efforts to improve maternal and child health in Malawi, maternal and newborn mortality rates remain very high, with the country having one of the highest maternal mortality ratios globally. The aim of this study was to identify which individual factors best predict utilisation of skilled maternal healthcare in a sample of women residing in Lilongwe district of Malawi. Identifying which of these factors play a significant role in determining utilisation of skilled maternal healthcare is required to inform policies and programming in the interest of achieving increased utilisation of skilled maternal healthcare in Malawi. METHODS: This study used secondary data from the Woman's Questionnaire of the 2010 Malawi Demographic and Health Survey (MDHS). Data was analysed from 1126 women aged between 15 and 49 living in Lilongwe. Multivariate logistic regression was conducted to determine significant predictors of maternal healthcare utilisation. RESULTS: Women's residence (P=.006), education (P=.004), and wealth (P=.018) were significant predictors of utilisation of maternal healthcare provided by a skilled attendant. Urban women were less likely (odds ratio [OR] = 0.47, P=.006, 95% CI = 0.28-0.81) to utilise a continuum of maternal healthcare from a skilled health attendant compared to rural women. Similarly, women with less education (OR = 0.32, P=.001, 95% CI = 0.16-0.64), and poor women (OR = 0.50, P=.04, 95% CI = 0.26-0.97) were less likely to use a continuum of maternal healthcare from a skilled health attendant. CONCLUSION: Policies and programmes should aim to increase utilisation of skilled maternal healthcare for women with less education and low-income status. Specifically, emphasis should be placed on promoting education and economic empowerment initiatives, and creating awareness about use of maternal healthcare services among girls, women and their respective communities.

A narrative synthesis scoping review of life course domains within health service utilisation frameworks.

Background: Current thinking in health recognises the influence of early life experiences (health and otherwise) on later life outcomes. The life course approach has been embedded in the work of the World Health Organisation since the Ageing and Health programme was established in 1995. Yet there has been limited debate on the relevancy of a life course lens to understanding health service utilisation. Aim: The aim of the review was twofold. Firstly, identify existing healthcare utilisation frameworks other than the dominant Andersen's behavioural model currently in use. Secondly, to identify if current frameworks incorporate the advocated life course perspective in understanding health service utilisation.     Methods: A scoping review of PubMed, Cinahl Plus, Emerald, PsycINFO, Web of Knowledge and Scopus was conducted. Data extraction used a framework approach with meta-synthesis guided by the four domains of the life course proposed by Elder (1979): human agency, location, temporality and relationships, and interdependencies. Results: A total of 551 papers were identified, with 70 unique frameworks (other than Andersen's Behavioural Model) meeting the inclusion criteria and included in the review. Conclusion: To date there has been limited explicit discussion of health service utilisation from a life course perspective. The current review highlights a range of frameworks that draw on aspects of the life course, but have been used with this perspective in mind. The life course approach highlights important gaps in understanding and assessing health service utilisation (HSU), such as utilisation over time. HSU is a complex phenomenon and applying a structured framework from a life course perspective would be of benefit to researchers, practitioners and policy makers.

The perceived needs-access gap for health services among persons with disabilities in a rural area within South Africa.

Purpose: Health should be a universal phenomenon. However, little is known about the relationship between disability status and health issues - particularly in rural areas. This study looks at health issues of persons with disabilities in Madwaleni, a rural impoverished area in South Africa in 2011, and compares them to persons with no disabilities. Materials and Methods: Standardized questionnaires were used in the survey to assess disability and health status. The sample comprised of 773 individuals - 322 persons with disability and 451 comparisons (without disability) - covering 527 households. Children under the age of five were excluded from the sample. We used purposive sampling. Results and Conclusion: This study found that persons with disabilities have poorer reported health outcomes than persons with no disabilities. There is also an association between disability severity and mental health issues as assessed by the GHQ-12. A significantly higher percentage of persons with disability did not get health care when needed. Persons with disabilities also have less favorable attitudes toward competence of health care workers. This study has shown greater health needs and less satisfaction with services, which strongly indicates insufficient access for persons with disabilities in a rural impoverished are within South Africa. Implications for rehabilitation Persons with disabilities in rural South Africa have poorer reported health outcomes. Persons with disabilities have less favorable attitudes towards competence of health care workers in rural South Africa. Better access to health care for persons with disabilities is needed in rural South Africa.

Enabling appropriate personnel skill-mix for progressive realization of equitable access to assistive technology.

BACKGROUND AND METHODS: This paper reviews the current capacity of personnel in enabling access to assistive technology (AT) as well as the systems and processes within which they work, and was reviewed, discussed, and refined during and following the Global Research, Innovation, and Education in Assistive Technology (GREAT) Summit. FINDINGS: Key concepts addressed include a person-centred team approach; sustainability indicators to monitor, measure, and respond to needs for service design and delivery; education, research, and training for competent practice, using the six rehab-workforce challenges framework; and credentialing frameworks. We propose development of a competence framework and associated education and training programs, and development and implementation of a certification framework for AT personnel. CONCLUSIONS: There is a resolve to address the challenges faced by People globally to access assistive technology. Context specific needs assessment is required to understand the AT Personnel landscape, to shape and strengthen credentialing frameworks through competencies and certification, acknowledging both general and specific skill mix requirements. Implications for Rehabilitation Personnel in assistive technology (AT) provision should be trained using a person-centred team approach, which emphasizes appropriate skill-mix to address multiple needs within the community. Sustainability indicators should be used which allow personnel to monitor, measure and respond to needs for service design and delivery. A competence framework with associated education and training program, coupled with the development and implementation of a certification framework for AT personnel needs, will promote quality in AT personnel training globally.

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

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

HIV/AIDS knowledge, attitudes and behaviour of persons with and without disabilities from the Uganda Demographic and Health Survey 2011: Differential access to HIV/AIDS information and services.

Uganda is among the first to use the Washington Group Short Set of Questions on Disability to identify persons with disabilities in its Demographic and Health Survey. In this paper, we review the HIV Knowledge, Attitudes and Behaviour component of the 2011 Ugandan Demographic and Health Survey, analysing a series of questions comparing those with and without disabilities in relation to HIV/AIDS knowledge, attitudes and practices. We found comparable levels of knowledge on HIV/AIDS for those with and those without disabilities in relation to HIV transmission during delivery (93.89%, 93.26%) and through breastfeeding (89.91%, 90.63%), which may reflect increased attention to reaching the community of persons with disabilities. However, several gaps in the knowledge base of persons with disabilities stood out, including misconceptions of risk of HIV infection through mosquito bites and caring for a relative with HIV in own household (34.39%, 29.86%; p<0.001; 91.53%, 89.00%; p = 0.001, respectively). The issue is not just access to appropriate information but also equitable access to HIV/AIDS services and support. Here we found that persons with multiple disabilities were less likely than individuals without disabilities to return to receive results from their most recent HIV test (0.60[0.41-0.87], p<0.05). HIV testing means little if people do not return for follow-up to know their HIV status and, if necessary, to be connected to available services and supports. Additional findings of note were that persons with disabilities reported having a first sexual encounter at a slightly younger age than peers without disabilities; and persons with disabilities also reported having a sexually transmitted disease (STD) within the last 12 months at significantly higher rates than peers without disabilities (1.38[1.18-1.63], p<0.01), despite reporting comparable knowledge of the need for safer sex practices. This analysis is among the first to use HIV/AIDS-related questions from Demographic Health Surveys to provide information about persons with disabilities in Uganda in comparison to those without disabilities. These findings present a more complex and nuanced understanding of persons with disabilities and HIV/AIDS. If persons with disabilities are becoming sexually active earlier, are more likely to have an STD within the preceding 12 month period and are less likely to receive HIV test results, it is important to understand why. Recommendations are also made for the inclusion of disability measures in Uganda's AIDS Indicator Survey to provide cyclical and systematic data on disability and HIV/AIDS, including HIV prevalence amongst persons with disabilities.