Advancing disability-inclusive climate research and action, climate justice, and climate-resilient development.

Globally, more than 1 billion people with disabilities are disproportionately and differentially at risk from the climate crisis. Yet there is a notable absence of climate policy, programming, and research at the intersection of disability and climate change. Advancing climate justice urgently requires accelerated disability-inclusive climate action. We present pivotal research recommendations and guidance to advance disability-inclusive climate research and responses identified by a global interdisciplinary group of experts in disability, climate change, sustainable development, public health, environmental justice, humanitarianism, gender, Indigeneity, mental health, law, and planetary health. Climate-resilient development is a framework for enabling universal sustainable development. Advancing inclusive climate-resilient development requires a disability human rights approach that deepens understanding of how societal choices and actions-characterised by meaningful participation, inclusion, knowledge diversity in decision making, and co-design by and with people with disabilities and their representative organisations-build collective climate resilience benefiting disability communities and society at large while advancing planetary health.

Road traffic injuries in Namibia: health services, public health and the motor vehicle accident fund.

Namibia is one of five countries in sub-Saharan Africa that has a fuel tax levy designed to support road injury victims. This study examines how the scheme operates from the perspective of seriously injured or permanently disabled beneficiaries. Using qualitative methods, we conducted semi-structured interviews with RTI survivors in Namibia, and healthcare workers involved in caring for them, in order to investigate the role played by the MVAF. While some wealthier drivers continue to buy private insurance, most Namibians now rely on the MVAF. The analysis show the MVAF is effectively helping to enhance access to rehabilitation and other health services for RTI survivors. There however exist some weaknesses in the system which can be addressed. It is hoped these findings will contribute to discussions about whether the current system is fit for purpose and could serve as a replicable model in other low and middle-income countries (LMICs).

The impact of an inclusive education intervention on learning outcomes for girls with disabilities within a resource-poor setting.

BACKGROUND: Despite a global commitment to the right to education for persons with disabilities, little is known about how to achieve inclusive education in practice, particularly in low- and middle-income countries (LMICs), where the majority of the world's people with disabilities reside. Moreover, although exclusion from education is magnified by intersecting gender and socioeconomic inequalities, there is especially little knowledge regarding what approaches to inclusive education are effective amongst girls with disabilities living in resource-poor settings. OBJECTIVES: The objective of this article was to assess the impact of an inclusive education intervention led by a non-governmental organisation (NGO) on the educational attainment of girls with disabilities in the resource-poor Lakes region of Kenya. METHOD: A quasi-experimental design was employed, where the literacy and numeracy educational attainment of the intervention and control groups was compared over two time points a year apart (Time 1 and Time 2; total matched N = 353). During this period, activities pertaining to six core components of a holistic inclusive education model were implemented. RESULTS: Relative to the control group, girls with disabilities in the intervention group reported a greater increase in literacy and numeracy attainment, adjusted for grade and level of functional difficulty. CONCLUSION: Findings suggest that the intervention was successful in engendering additional improvements in the educational attainment of girls with disabilities from the resource-poor Lakes region of Kenya. Results highlight both the applicability of NGO-led interventions in settings, where national implementation of inclusive education is constrained, and the potential of taking such interventions to scale.

Prevalence and Predictors of Smoking among Gambian Men: A Cross-Sectional National WHO STEP Survey.

BACKGROUND: Tobacco use is the leading cause of preventable death in the world, with a higher burden in low- and middle-income countries. The aim of this study was to quantify the prevalence and predictors of smoking among Gambian men using nationally representative data. METHODS: Data was collected in 2010 from a random, nationally representative sample of 4111 adults aged 25-64 years (78% response rate) using the World Health Organization (WHO) STEPwise cross-sectional survey methods. Our analyses focused on men with valid information on smoking status (n = 1766) because of the low prevalence of smoking among women (1%). RESULTS: The prevalence of current smoking among men was 31.4% (95% CI: 27.2-35.9). The median age of starting smoking was 19 years; 25% started before the age of 18 years and 10% started aged 8-10 years. Rural residence, underweight, and hypertension were significantly associated with smoking. CONCLUSION: The study reveals a high prevalence of smoking among Gambian men. It is evident that cigarettes are obtained by minors in The Gambia, as a high proportion of current smokers started at a young age. Advice and support to quit smoking should be extended to all smokers regardless of their age and whether or not they have any underlying health conditions.

Inter- and intra-household perceived relative inequality among disabled and non-disabled people in Liberia.

Evidence suggests that people with disabilities are the most marginalised and vulnerable group within any population. However, little is known about the extent of inequality between people with and without disabilities in contexts where the majority of persons experience extreme poverty and hardship. This includes in Liberia, where very little is understood about the lives of disabled people in general. This study uses a multidimensional wellbeing framework to understand perceived relative inequality associated with disability by assessing several facets of wellbeing across and within households containing disabled members (N = 485) or households with no disabled members (N = 538) in Liberian communities (Total individuals surveyed, N = 2020). Statistical comparisons (adjusted for age, sex, education and wealth differences and clustered at the household, village and county level) reveal that disabled Liberians are managing similarly to non-disabled Liberians in terms of income and education, but experience many perceived relative inequalities including in life satisfaction, transport access, political participation and social inclusion. Our results further suggest that disability may lead to perceived relative inequality at the household level in terms of trust held in neighbours. However, they also show that being the head of a household may protect against perceived relative inequality in certain dimensions (e.g. healthcare and transport access, political participation) irrespective of disability status. Results are discussed in terms of practical implications for development efforts in Liberia and for disabled people in other low- and middle-income settings.

Are maternal healthcare services accessible to vulnerable group? A study among women with disabilities in rural Nepal.

BACKGROUND: Studies report that vulnerable groups like people with disabilities have less access to healthcare. This study compares health service access between women with and without disabilities in general and explores the challenges encountered by women with disabilities in accessing maternal healthcare services during pregnancy. METHODS: A mixed method study was conducted in Rupandehi district of Nepal implementing a cross-sectional survey among 354 women including 79 women with disabilities, supplemented by 43 in-depth interviews. Descriptive and bivariate statistical analysis of quantitative data using Pearson's Chi-square test for association was carried out, while qualitative data were analysed following the theme content analysis using a framework approach. RESULTS: The vast majority of women from both groups, women with and without disabilities (71% vs 74%) reported that the nearest health facility from their location was more than 30 minutes walking distance (P>0.05). Half of the women with disabilities walked to health facilities for ANC check-ups. Over one-third of women without disabilities and a slightly lesser proportion of women with disabilities (29%) used a low-cost means of transport (rikshaw, bi/tri-cycles) (P>0.05). Distribution of health facilities found uneven and poorly linked with road transport facilities. None of the health facilities accommodated the needs of women with disabilities with accessible buildings and convenient opening time. The travel cost and the extra cost of services, staff shortage, often delayed and inadequate drug supplies were common problems for both women with and without disabilities. Unavailability of beds during delivery, insensitive providers with negative attitudes and abusive behaviour, inadequate knowledge and experience in providing services to the people with disabilities as well as unwelcoming health facility environment made services particularly inaccessible to women with disabilities. CONCLUSION: Maternal healthcare services are not easily and equitably accessible to women with disabilities. To increase access to healthcare for this vulnerable group, improvements are needed in distribution and management of resources from transportation through service delivery, as well as improved provider knowledge and awareness of a human rights approach to disability and health.

Socioeconomic inequality in recovery from poor physical and mental health in mid-life and early old age: prospective Whitehall II cohort study.

BACKGROUND: Few studies have examined the influence of socioeconomic status on recovery from poor physical and mental health. METHODS: Prospective study with four consecutive periods of follow-up (1991-2011) of 7564 civil servants (2228 women) recruited while working in London. Health was measured by the Short-Form 36 questionnaire physical and mental component scores assessed at beginning and end of each of four rounds. Poor health was defined by a score in the lowest 20% of the age-sex-specific distribution. Recovery was defined as changing from a low score at the beginning to a normal score at the end of the round. The analysis took account of retirement status, health behaviours, body mass index and prevalent chronic disease. RESULTS: Of 24 001 person-observations in the age range 39-83, a total of 8105 identified poor physical or mental health. Lower grade of employment was strongly associated with slower recovery from poor physical health (OR 0.73 (95% CI 0.59 to 0.91); trend P=0.002) in age, sex and ethnicity-adjusted analyses. The association was halved after further adjustment for health behaviours, adiposity, systolic blood pressure (SBP) and serum cholesterol (OR 0.85 (0.68 to 1.07)). In contrast, slower recovery from poor mental health was associated robustly with low employment grade even after multiple adjustment (OR 0.74 (0.59 to 0.93); trend P=0.02). CONCLUSIONS: Socioeconomic inequalities in recovery from poor physical health were explained to a considerable extent by health behaviours, adiposity, SBP and serum cholesterol. These risk factors explained only part of the gradient in recovery for poor mental health.

Infectious causes of microcephaly: epidemiology, pathogenesis, diagnosis, and management.

Microcephaly is an important sign of neurological malformation and a predictor of future disability. The 2015-16 outbreak of Zika virus and congenital Zika infection brought the world's attention to links between Zika infection and microcephaly. However, Zika virus is only one of the infectious causes of microcephaly and, although the contexts in which they occur vary greatly, all are of concern. In this Review, we summarise important aspects of major congenital infections that can cause microcephaly, and describe the epidemiology, transmission, clinical features, pathogenesis, management, and long-term consequences of these infections. We include infections that cause substantial impairment: cytomegalovirus, herpes simplex virus, rubella virus, Toxoplasma gondii, and Zika virus. We highlight potential issues with classification of microcephaly and show how some infants affected by congenital infection might be missed or incorrectly diagnosed. Although Zika virus has brought the attention of the world to the problem of microcephaly, prevention of all infectious causes of microcephaly and appropriately managing its consequences remain important global public health priorities.

Do experiences and perceptions about quality of care differ among social groups in Nepal? : A study of maternal healthcare experiences of women with and without disabilities, and Dalit and non-Dalit women.

BACKGROUND: Suboptimal quality of care and disparities in services by healthcare providers are often reported in Nepal. Experience and perceptions about quality of care may differ according to women's socio-cultural background, individual characteristics, their exposure and expectations. This study aimed to compare perceptions of the quality of maternal healthcare services between two groups that are consistently considered vulnerable, women with disabilities from both the non-Dalit population and Dalit population and their peers without disabilities from both non-Dalit and Dalit communities. METHODS: A cross-sectional survey was conducted among 343 total women that included women with disabilities, Dalits and non-Dalits. Women were recruited for interview, who were aged 15-49 years, had been pregnant within the last five years and who had used maternal care services in one of the public health facilities of Rupandehi district. A 20-item, Likert-type scale with four sub-scales or dimensions: 'Health Facility', 'Healthcare Delivery', 'Inter-personal' and 'Access to Care' was used to measure women's perceptions of quality of care. Chi-square test and t test were used to compare groups and to assess differences in perceptions; and linear regression was applied to assess confounding effects of socio-demographic factors. The mean score was compared for each item and separately for each dimension. RESULTS: All groups, women with disabilities and women without disabilities, Dalit and non-Dalit rated their perceptions and experiences of quality of care lowly in a number of items. While perceived quality of care between women with disabilities and without disabilities in the 'Health Facility' dimension and associated items, was found to differ (p<0.05), this difference was linked to disability status, but was not linked to caste differences. For example, differences in mean scores relating to 'Cleanliness and Facilities', 'Open and Friendliness' and 'Compassion and Kindness' were highly significant (p<0.001), with women with disabilities rating these as better than women without disabilities. On the other hand, women without disabilities rated the 'Availability of cash Incentives' more highly (p<0.01). No significant differences were found between Dalit and non-Dalit women in perceived quality of care, except in relation to 'Cleanliness and facilities', which Dalit women rated lower than non-Dalits (p<0.05). CONCLUSIONS: Perceptions about the quality of care differed significantly by disability status but not by caste. All groups rated the quality of healthcare delivery, interpersonal and personal factors as well as access to services 'low.' Poor service user experiences and perceptions of quality of care undermine opportunities to translate increased healthcare coverage into improved access and outcomes. Greater attention is required by policy makers, health planners and providers to the improvement of quality of care in health facilities.

Extra costs of living with a disability: A review and agenda for research.

BACKGROUND: There has been a growing interest in disability and poverty on the international research and policy stages. Poverty assessments for persons with disabilities may be affected by the experience of extra costs associated with a disability. OBJECTIVE: This article provides a systematized review of the global literature on the direct costs associated with living with a disability at the individual or household level. METHODS: We searched three databases for peer-reviewed journal articles that estimated extra costs associated with disability: Econlit, SocIndex and PubMed. RESULTS: We found 20 such studies conducted in 10 countries. These studies were predominantly from high-income countries. Although studies were heterogeneous (e.g., in terms of disability measures and cost methodologies), estimated costs were sizeable and some patterns were consistent across studies. Costs varied according to the severity of disability, life cycle and household composition. Highest costs were observed among persons with severe disabilities, and among persons with disabilities living alone or in small sized households. CONCLUSIONS: More quantitative evidence is needed using rigorous methods, for instance evidence based on longitudinal data and as part of policy evaluations. More internationally comparable data on disability is required for the quantitative evidence to develop, especially in low- and middle-income countries where studies are scarce. Qualitative and participatory research is also needed, especially to investigate unmet needs, and the consequences of extra costs.

Can Households Cope with Health Shocks in Vietnam?

This paper investigates the economic impact of health shocks on working-age adults in Vietnam during 2004-2008, using a fixed effects specification. Health shocks cover disability and morbidity and are measured by 'days unable to carry out regular activity', 'days in bed due to illness/injury', and 'hospitalization'. Overall, Vietnamese households are able to smooth total non-health expenditures in the short run in the face of a significant rise in out-of-pocket health expenditures. However, this is accomplished through vulnerability-enhancing mechanisms, especially in rural areas, including increased loans and asset sales and decreased education expenditures. Female-headed and rural households are found to be the least able to protect consumption. Results highlight the need to extend and deepen social protection and universal health coverage. © 2015 The Authors. Health Economics published by John Wiley & Sons Ltd.

The Economic Lives of People with Disabilities in Vietnam.

Through a series of focus group discussions conducted in northern and central Vietnam, this study gives voice to the lived economic experience of families with disabilities and how they manage the economic challenges associated with disability. The dynamic of low and unstable income combined with on-going health care and other disability-related costs gives rise to a range of coping mechanisms (borrowing, reducing and foregoing expenditures, drawing upon savings and substituting labour) that helps to maintain living standards in the short-run yet threatens the longer-term welfare of both the individual with disability and their household. Current social protection programs were reported as not accessible to all and while addressing some immediate economic costs of disability, do not successfully meet current needs nor accommodate wider barriers to availing benefits.

Mental illness, poverty and stigma in India: a case-control study.

OBJECTIVE: To assess the effect of experienced stigma on depth of multidimensional poverty of persons with severe mental illness (PSMI) in Delhi, India, controlling for gender, age and caste. DESIGN: Matching case (hospital)-control (population) study. SETTING: University Hospital (cases) and National Capital Region (controls), India. PARTICIPANTS: A case-control study was conducted from November 2011 to June 2012. 647 cases diagnosed with schizophrenia or affective disorders were recruited and 647 individuals of same age, sex and location of residence were matched as controls at a ratio of 1:2:1. Individuals who refused consent or provided incomplete interview were excluded. MAIN OUTCOME MEASURES: Higher risk of poverty due to stigma among PSMI. RESULTS: 38.5% of PSMI compared with 22.2% of controls were found poor on six dimensions or more. The difference in multidimensional poverty index was 69% between groups with employment and income of the main contributors. Multidimensional poverty was strongly associated with stigma (OR 2.60, 95% CI 1.27 to 5.31), scheduled castes/scheduled tribes/other backward castes (2.39, 1.39 to 4.08), mental illness (2.07, 1.25 to 3.41) and female gender (1.87, 1.36 to 2.58). A significant interaction between stigma, mental illness and gender or caste indicates female PSMI or PSMI from 'lower castes' were more likely to be poor due to stigma than male controls (p<0.001) or controls from other castes (p<0.001). CONCLUSIONS: Public stigma and multidimensional poverty linked to SMI are pervasive and intertwined. In particular for low caste and women, it is a strong predictor of poverty. Exclusion from employment linked to negative attitudes and lack of income are the highest contributors to multidimensional poverty, increasing the burden for the family. Mental health professionals need to be aware of and address these issues.

The impact of health insurance for children under age 6 in Vietnam: A regression discontinuity approach.

Accessing health services at an early age is important to future health and life outcomes. Yet, little is currently known on the role of health insurance in facilitating access to care for children. Exploiting a regression discontinuity design made possible through a policy to provide health insurance to pre-school aged children in Vietnam, this paper evaluates the impact of health insurance on the health care utilization outcomes of children at the eligibility threshold of six years. Using three rounds of the Vietnam Household Living Standards Survey, the study finds a positive impact on inpatient and outpatient visits and no significant impact on expenditures per visit at public facilities. We find moderately high use of private outpatient services and no evidence of a switch from private to covered public facilities under insurance. Results suggest that adopting public health insurance programs for children under age 6 may be an important vehicle to improving service utilization in a low- and middle-income country context. Challenges remain in providing adequate protections from the costs and other barriers to care.

Disabled women׳s maternal and newborn health care in rural Nepal: a qualitative study.

OBJECTIVE: there is little evidence about disabled women׳s access to maternal and newborn health services in low-income countries and few studies consult disabled women themselves to understand their experience of care and care seeking. Our study explores disabled women׳s experiences of maternal and newborn care in rural Nepal. DESIGN: we used a qualitative methodology, using semi-structured interviews. SETTING: rural Makwanpur District of central Nepal. PARTICIPANTS: we purposively sampled married women with different impairments who had delivered a baby in the past 10 years from different topographical areas of the district. We also interviewed maternal health workers. We compared our findings with a recent qualitative study of non-disabled women in the same district to explore the differences between disabled and non-disabled women. FINDINGS: married disabled women considered pregnancy and childbirth to be normal and preferred to deliver at home. Issues of quality, cost and lack of family support were as pertinent for disabled women as they were for their non-disabled peers. Health workers felt unprepared to meet the maternal health needs of disabled women. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: integration of disability into existing Skilled Birth Attendant training curricula may improve maternal health care for disabled women. There is a need to monitor progress of interventions that encourage institutional delivery through the use of disaggregated data, to check that disabled women are benefiting equally in efforts to improve access to maternal health care.