Health equity for persons with disabilities: a global scoping review on barriers and interventions in healthcare services.

BACKGROUND: Persons with disabilities experience health inequities in terms of increased mortality, morbidity, and limitations in functioning when compared to the rest of the population. Many of the poor health outcomes experienced by persons with disabilities cannot be explained by the underlying health condition or impairment, but are health inequities driven by unfair societal and health system factors. A synthesis of the global evidence is needed to identify the factors that hinder equitable access to healthcare services for persons with disabilities, and the interventions to remove these barriers and promote disability inclusion. METHODS: We conducted a scoping review following the methodological framework proposed by Arksey and O'Malley, Int J Soc Res Methodol 8:19-32. We searched two scholarly databases, namely MEDLINE (Ovid) and Web of Science, the websites of Organizations of Persons with Disabilities and governments, and reviewed evidence shared during WHO-led consultations on the topic of health equity for persons with disabilities. We included articles published after 2011 with no restriction to geographical location, the type of underlying impairments or healthcare services. A charting form was developed and used to extract the relevant information for each included article. RESULTS: Of 11,884 articles identified in the search, we included 182 articles in this review. The majority of sources originated from high-income countries. Barriers were identified worldwide across different levels of the health system (such as healthcare costs, untrained healthcare workforces, issues of inclusive and coordinated services delivery), and through wider contributing factors of health inequities that expand beyond the health system (such as societal stigma or health literacy). However, the interventions to promote equitable access to healthcare services for persons with disabilities were not readily mapped onto those needs, their sources of funding and projected sustainability were often unclear, and few offered targeted approaches to address issues faced by marginalized groups of persons with disabilities with intersectional identities. CONCLUSION: Persons with disabilities continue to face considerable barriers when accessing healthcare services, which negatively affects their chances of achieving their highest attainable standard of health. It is encouraging to note the increasing evidence on interventions targeting equitable access to healthcare services, but they remain too few and sparce to meet the populations' needs. Profound systemic changes and action-oriented strategies are warranted to promote health equity for persons with disabilities, and advance global health priorities.

Integrating competency analysis into national rehabilitation workforce evaluation: a case study.

BACKGROUND: Establishing a workforce capable of meeting population needs is contingent on evaluation that can inform sound policy and planning. Health workforce evaluation has traditionally relied on health labour market analysis and workload estimations. To date, competency analysis has not been included in national health workforce evaluation, despite that fact that the findings may go far in guiding decisions around workforce composition, optimisation and education and training. This case study sought to assess the feasibility and perceived added value of integrating competency analysis into national rehabilitation workforce evaluation, and to determine how competency analysis can shape rehabilitation workforce planning. The findings of the case study can be used to explore the integration of competency analysis in the evaluation of other health-related occupational groups. METHODS: Participant observation was complemented by key informant interviews with experts engaged in the national rehabilitation workforce evaluation in Poland. These experts represented stakeholders in policy, education, research, clinical practice and professional associations. RESULTS: The results indicated that competency analysis can be feasibly integrated into national rehabilitation workforce evaluation, particularly when implementation is supported through the use of online platforms. However, the collection of additional data using other tools, such as a survey of the behaviours and tasks of a wider sample of rehabilitation workers, could strengthen data reliability. Experts perceived findings of the competency analysis to be valuable for expanding the understanding of rehabilitation, shedding light on task allocation and deployment of the existing rehabilitation workforce, and advocating for the rehabilitation workforce to be strengthened, especially in relation to those occupations which may not be recognised or valued as rehabilitation workers. Although it was not possible to fully explore the impact of competency analysis data on rehabilitation workforce planning and development in this study, experts suggested that its availability would likely foster greater cooperation among occupations, which has been missing at the policy and planning level to date. It further demonstrates what competency data should be collected and reported, and provides richer information to guide decisions. CONCLUSIONS: Competency analysis complements traditional labour market analysis and workload estimates, adding depth to the understanding of how members of the workforce perform and perceive themselves, and how deficiencies in the workforce impact on the provision of care to specific population groups.

Measurement Properties and Minimal Important Change of the World Health Organization Disability Assessment Schedule 2.0 in Persons With Low Back Pain: A Systematic Review.

OBJECTIVE: To determine the measurement properties and minimal important change (MIC) of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) short (12 questions) and full (36 questions) versions in persons with nonspecific low back pain (LBP). DATA SOURCES: MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, APA PsycInfo, and Cochrane Central Register of Controlled Trials (inception to May 2021). STUDY SELECTION: Eligible studies assessed measurement properties or MIC of WHODAS 2.0 in persons with LBP. DATA EXTRACTION: Paired reviewers screened articles, extracted data, and assessed risk of bias using Consensus-Based Standards for Selection of Health Measurement Instruments (COSMIN) and COSMIN-Outcome Measures in Rheumatology checklists. DATA SYNTHESIS: We descriptively synthesized results stratified by measurement property and LBP duration (subacute: 6 weeks to 3 months; chronic: ≥3 months). RESULTS: We screened 297 citations and included 14 studies (reported in 15 articles). Methodological quality of studies was very good for internal consistency and varied between very good and doubtful for construct validity, doubtful for responsiveness, and adequate for all other properties assessed. Evidence suggests that WHODAS 2.0 full version has adequate content validity (2 studies); WHODAS 2.0 short and full versions have adequate structural validity (3 studies), but construct validity is indeterminate (9 studies). WHODAS 2.0 short and full versions have adequate internal consistency (10 studies), and the full version has adequate test-retest and interrater reliability (3 studies) in persons with LBP. Minimal detectable change (MDC) was 10.45-13.99 of 100 for the full version and 8.6 of 48 for the short version in persons with LBP (4 studies). WHODAS 2.0 full version has no floor or ceiling effects, but the short version has potential floor effects in persons with chronic LBP (3 studies). One study estimated MIC for the full version as 4.87 of 100 or 9.74 of 100 (corresponding to 1- and 2-point change on 0- to 10-cm visual analog scale for pain, respectively), and 1 study estimated 3.09-4.68 of 48 for the short version. CONCLUSIONS: In persons with LBP, WHODAS 2.0 full version has adequate content validity, structural validity, internal consistency, and reliability. WHODAS 2.0 short version has adequate structural validity and internal consistency. Construct validity of the short and full versions is indeterminate. Since MDC is estimated to be larger than MIC, users may consider both MIC and MDC thresholds to measure change in functioning for LBP.

Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019.

BACKGROUND: Rehabilitation has often been seen as a disability-specific service needed by only few of the population. Despite its individual and societal benefits, rehabilitation has not been prioritised in countries and is under-resourced. We present global, regional, and country data for the number of people who would benefit from rehabilitation at least once during the course of their disabling illness or injury. METHODS: To estimate the need for rehabilitation, data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 were used to calculate the prevalence and years of life lived with disability (YLDs) of 25 diseases, impairments, or bespoke aggregations of sequelae that were selected as amenable to rehabilitation. All analyses were done at the country level and then aggregated to seven regions: World Bank high-income countries and the six WHO regions (ie, Africa, the Americas, Southeast Asia, Europe, Eastern Mediterranean, and Western Pacific). FINDINGS: Globally, in 2019, 2·41 billion (95% uncertainty interval 2·34-2·50) individuals had conditions that would benefit from rehabilitation, contributing to 310 million [235-392] YLDs. This number had increased by 63% from 1990 to 2019. Regionally, the Western Pacific had the highest need of rehabilitation services (610 million people [588-636] and 83 million YLDs [62-106]). The disease area that contributed most to prevalence was musculoskeletal disorders (1·71 billion people [1·68-1·80]), with low back pain being the most prevalent condition in 134 of the 204 countries analysed. INTERPRETATION: To our knowledge, this is the first study to produce a global estimate of the need for rehabilitation services and to show that at least one in every three people in the world needs rehabilitation at some point in the course of their illness or injury. This number counters the common view of rehabilitation as a service required by only few people. We argue that rehabilitation needs to be brought close to communities as an integral part of primary health care to reach more people in need. FUNDING: Bill & Melinda Gates Foundation.

Promoting equity in health emergencies through health systems strengthening: lessons learned from disability inclusion in the COVID-19 pandemic.

Discriminatory health systems and inequalities in service provision inevitably create barriers for certain populations in a health emergency. Persons with disabilities have been disproportionately affected by the COVID-19 pandemic. They commonly experience three increased risks - of contracting the disease, of severe disease or death, and of new or worsening health conditions. These added risks occur due to a range of barriers in the health sector, including physical barriers that prevent access to health facilities and specific interventions; informational barriers that prevent access to health information and/or reduce health literacy; and attitudinal barriers which give rise to stigma and exclusion, all of which add to discrimination and inequality. Furthermore, national health emergency preparedness and planning may fail to consider the needs and priorities of persons with disabilities, in all their diversity, thus leaving them behind in responses. This commentary discusses the importance of inclusive health systems strengthening as a prerequisite for accessible and comprehensive health emergency preparedness and response plans that reach everyone. Lessons learned relating to disability inclusion in the COVID-19 pandemic can inform health systems strengthening in recovery efforts, addressing underlying barriers to access and inclusion, and in turn improving preparedness for future health emergencies.

Development of the WHO STARS: A Tool for the Systematic Assessment of Rehabilitation Situation.

OBJECTIVE: To present the development process of the World Health Organization (WHO) Systematic Assessment of Rehabilitation Situation (STARS). DESIGN: A conceptualization phase to establish its objective and identify the content for comprehensively describing rehabilitation in countries, a second phase to draft, and a third phase to refine the tool. Reviews of existing health system assessment (HSA) tools used in other areas of health as well as expert consultations occurred. SETTING: The WHO initiated the development of STARS because there is currently no comprehensive HSA tool for rehabilitation that supports stakeholders describing their country situation and identifying priority actions. PARTICIPANTS: The WHO rehabilitation team, experts representing rehabilitation professions and from all WHO regions, and government and rehabilitation consumer groups. INTERVENTIONS: Conceptualizing, drafting, consulting, and reviewing of the WHO STARS. MAIN OUTCOMES MEASURES: Development of a tool that is comprehensive and able to support countries to describe rehabilitation and identify priorities. RESULTS: STARS was developed in a participatory process, uses a logic model to structure the 50 components of rehabilitation selected for assessment, and assesses both capacity and performance. CONCLUSIONS: STARS is the first HSA shaped to rehabilitation, has been developed by the WHO in a participatory process based on several expert consultations, and has the potential to meaningfully support governments to better understand the status of rehabilitation in their countries, define priorities for action to strengthen rehabilitation, and facilitate the monitoring of system level changes. Moreover, STARS information can be used in research to support evidence-informed policy and programs.

Demographic and environmental factors associated with disability in India, Laos, and Tajikistan: a population-based cross-sectional study.

BACKGROUND: The number of people experiencing functional limitations due to health conditions (capacity) is expected to increase in low and middle-income countries as populations age and rates of non-communicable disease rise. This trend could raise the prevalence and levels of disability worldwide. Understanding the demographic and environmental factors associated with disability can inform the design of policy interventions to make societies more accessible and inclusive for all. METHODS: Approximately 2,500-3,000 participants in each of India, Laos, and Tajikistan responded to the Gallup World Poll and the World Health Organization's Brief Model Disability Survey through face-to-face interviews. For each country, random forest regression was performed to explore the associations of demographic and environmental factors with disability while controlling for capacity. Using the variable importance measures generated by the random forest models, linear regression models were built in a stepwise manner for each country to predict disability level based on these contextual factors. RESULTS: Capacity was strongly associated with disability in all three countries. Most of the variance in disability was explained by minimally adjusted linear models that included only capacity, sex, and age. Inclusion of additional demographic factors and environmental factors explained slightly more of the variance in disability score. Across all three countries, the level of basic infrastructure, public services, and financial stability were moderately associated with disability. Age, sex, employment status, the use of assistive technologies, and other factors had associations with disability that were highly variable across countries. CONCLUSION: While capacity was the main determinant of disability, individual demographic and environmental factors were associated with disability in a country-specific manner while controlling for the effects of capacity.

Framing rehabilitation through health policy and systems research: priorities for strengthening rehabilitation.

BACKGROUND: Recent estimates report that 2.4 billion people with health conditions globally could benefit from rehabilitation. While the benefits of rehabilitation for individuals and society have been described in the literature, many individuals, especially in low- and middle-income countries do not have access to quality rehabilitation. As the need for rehabilitation continues to increase, it is crucial that health systems are adequately prepared to meet this need. Practice- and policy-relevant evidence plays an important role in health systems strengthening efforts. The aim of this paper is to report on the outcome of a global consultative process to advance the development of a research framework to stimulate health policy and systems research (HPSR) for rehabilitation, in order to generate evidence needed by key stakeholders. METHODS: A multi-stakeholder participatory technical consultation was convened by WHO to develop a research framework. This meeting included participants from selected Member States, rehabilitation experts, HPSR experts, public health researchers, civil society and other stakeholders from around the world. The meeting focused on introducing systems approaches to stakeholders and deliberating on priority rehabilitation issues in health systems. Participants were allocated to one of four multi-stakeholder groups with a facilitator to guide the structured technical consultations. Qualitative data in the form of written responses to guiding questions were collected during the structured technical consultations. A technical working group was then established to analyse the data and extract its emerging themes. This informed the development of the HPSR framework for rehabilitation and a selection of preliminary research questions that exemplify how the framework might be used. RESULTS: A total of 123 individuals participated in the multi-stakeholder technical consultations. The elaborated framework is informed by an ecological model and puts forth elements of the six WHO traditional building blocks of the health system, while emphasizing additional components pertinent to rehabilitation, such as political priority, engagement and participatory approaches, and considerations regarding demand and access. Importantly, the framework highlights the multilevel interactions needed across health systems in order to strengthen rehabilitation. Additionally, an initial set of research questions was proposed as a primer for how the framework might be used. CONCLUSIONS: Strengthening health systems to meet the increasing need for rehabilitation will require undertaking more HPSR to inform the integration of rehabilitation into health systems globally. We anticipate that the proposed framework and the emerging research questions will support countries in their quest to increase access to rehabilitation for their populations.

"Rehabilitation Research Framework for Patients With COVID-19" Defined by Cochrane Rehabilitation and the World Health Organization Rehabilitation Programme.

The coronavirus disease 2019 (COVID-19) pandemic resulted in a surge of research activity. Since its outset, efforts have been made to guide the rapid generation of research in medicine. There are gaps in some areas of rehabilitation research for patients with COVID-19. The development of a specific research framework might serve to help monitor the status of research (mapping), shape and strengthen research by pointing to under-investigated areas, and promote rehabilitation research in this context. This article introduces and discusses the COVID-19 Rehabilitation Research Framework (CRRF) and presents the methodology used for its development. The questions have been developed among the World Health Organization (WHO) Rehabilitation Programme, Cochrane Rehabilitation, and the experts of its Rehabilitation-COVID-19 Evidence-based Response Action International Multiprofessional Steering Committee. The framework is divided into 2 parts and includes 20 questions organized in 4 groups: epidemiology, and evidence at the micro- (individual), meso- (health services), and macro- (health systems) levels. The CRRF offers a comprehensive view of the research areas relevant to COVID-19 and rehabilitation that are necessary to inform best practice and ensure rehabilitation services and health systems can best serve the population with COVID-19. The collaboration between Cochrane Rehabilitation and the WHO Rehabilitation Programme in establishing the CRRF brought together perspectives from the health systems, health management, and clinical evidence. The authors encourage researchers to use the CRRF when planning studies on rehabilitation in the context of COVID-19.

Development and Validation of the WHO Rehabilitation Competency Framework: A Mixed Methods Study.

OBJECTIVES: To identify the competencies, behaviors, activities, and tasks required by the rehabilitation workforce, and their core values and beliefs, and to validate these among rehabilitation professionals and service users. DESIGN: Mixed methods study, involving a content analysis of rehabilitation-related competency frameworks, a modified Delphi study, and a consultation-based questionnaire of service users. SETTING: Desk-based research. PARTICIPANTS: Participants who completed the first (N=77; 47%) and second (N=68; 67%) iterations of the modified Delphi study. Thirty-seven individuals participated in the service user consultation. Collectively, the participants of the mixed methods study represented a significant range of rehabilitation professions from a broad range of countries, as well as both high- and low-income settings. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: The mixed methods study resulted in the inclusion of 4 core values, 4 core beliefs, 17 competencies, 56 behaviors, 20 activities, and 62 tasks in the Rehabilitation Competency Framework. The content analysis of rehabilitation-related competency frameworks produced an alpha list of competencies, behaviors, activities and tasks ("statements"), which were categorized into 5 domains. The final iteration of the modified Delphi study revealed an average of 95% agreement with the statements, whereas the service user consultation indicated an average of 87% agreement with the statements included in the questionnaire. CONCLUSIONS: Despite the diverse composition of the rehabilitation workforce, this mixed methods study demonstrated that a strong consensus on competencies and behaviors that are shared across professions, specializations, and settings, and for activities and tasks that collectively capture the scope of rehabilitation practice. The development of the Rehabilitation Competency Framework is a pivotal step toward the twin goals of building workforce capability to improve quality of care and strengthening a common rehabilitation workforce identity that will bolster its visibility and influence at a systems-level.

Proposing a re-conceptualisation of competency framework terminology for health: a scoping review.

BACKGROUND: Competency frameworks are being taken up by a growing number of sectors and for a broad range of applications. However, the topic of competency frameworks is characterised by conceptual ambiguity, misunderstanding and debate. Lack of consistency in the conceptualisation and use of key terminology creates a barrier to research and development, consensus, communication and collaboration, limiting the potential that competency frameworks have to deal with real workforce challenges. This paper aims to advance the field by conducting a detailed review of the literature to understand the underlying causes of conceptual differences and divergent views and proposing a re-conceptualisation of competency framework terminology for use by the health sector. METHODS: A broad scoping review of literature was conducted to identify publications relating to the conceptualisation of competency frameworks and key terms, examine how they are conceptualised and determine how this evolved. In addition, a purposive sample of health-related competency frameworks was chosen to illustrate how the terms and concepts are currently being applied in the health context. RESULTS: Of the 4 155 records identified, 623 underwent text searches and broad quantitative analysis, and 70 were included for qualitative analysis. Quantitative analysis identified 26 key terms, which were coded under six thematic headings. Qualitative analysis using the thematic areas revealed two distinct conceptualisations of competency frameworks and their terminology emerging concurrently in the education and employment sectors, with different underpinnings and purposes. As competency frameworks have developed, these two conceptualisations intertwined, resulting in the same terms being used to convey different concepts. Examination of health-related frameworks showed that this merging of concepts is prominent, with lack of consistency in definitions and use of key terms even within a single organisation. DISCUSSION AND CONCLUSIONS: Building on previous efforts to address the lack of conceptual clarity surrounding competency frameworks, this paper proposes a re-conceptualisation of the terminology that encompasses two distinct competency framework interpretations, using a glossary of mutually exclusive terms to differentiate concepts. The re-conceptualisation holds relevance for multiple competency framework applications within health, enabling harmonisation, clear communication, consensus-building and effective implementation of competency frameworks.

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition.

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

Rehabilitation the Health Strategy of the 21st Century, Really?

Rehabilitation is the care needed when a person is experiencing or is likely to experience limitations in everyday functioning due to aging or a health condition, including chronic diseases or disorders, injuries, or traumas. The changing health and demographic trends are contributing to rapid increases globally in numbers of people experiencing declines in functioning. Hence, rehabilitation needs that are already very high will further increase in the years to come. The question is: Is the field of rehabilitation with all its stakeholders ready to address that challenge? I argue that to move things forward and make sure that rehabilitation becomes a political priority under a unified message, rehabilitation stakeholders need to bring together the distinct portraits of rehabilitation under the concept of functioning. Also, the field of rehabilitation is still very fragmented and there is a need of a more unified advocacy by rehabilitation professional groups, by subspecialties and users. Responses to the paper are very welcome before, during, and after the second global Rehabilitation 2030 meeting on July 8 and 9, 2019.

Toward Strengthening Rehabilitation in Health Systems: Methods Used to Develop a WHO Package of Rehabilitation Interventions.

Achieving Universal Health Coverage (UHC) is a World Health Organization (WHO) strategic priority. UHC means "all people receive quality health services that meet their needs without being exposed to financial hardship in paying for the services." Rehabilitation is among the services included in UHC. As part of the WHO Rehabilitation 2030 call for action, WHO is developing its Package of Rehabilitation Interventions (PRI) to support ministries of health in planning, budgeting, and integrating rehabilitation interventions into health systems. The aim of this paper is to introduce and describe the PRI and its methodology. An advisory board composed of members from different WHO departments is overseeing the project, which is led by the WHO Rehabilitation Programme in collaboration with Cochrane Rehabilitation. The development of the PRI is conducted in 6 steps: (1) selection of health conditions (for which rehabilitation interventions will be included in the PRI) based on prevalences, related levels of disability, and expert opinion; (2) identification of rehabilitation interventions and related evidence for the selected health conditions from Clinical Practice Guidelines and Cochrane Reviews; (3) expert agreement on the inclusion of rehabilitation interventions in the PRI; (4) description of resources required for the provision of selected interventions; (5) peer review process, and (6) production of an open source web-based tool. Rehabilitation experts and consumers from all world regions will collaborate in the different steps. In developing the PRI, WHO is taking an important step toward strengthening rehabilitation in health systems, thus enabling more people to benefit from rehabilitation.

Difficulties Encountered by People With Depression and Anxiety on the Web: Qualitative Study and Web-Based Expert Survey.

BACKGROUND: Depression and anxiety are the most common mental health conditions, and they were identified as leading contributors to global disability in 2016. People with these conditions rely on Web-based resources as a source of accurate health information, convenient and effective treatment, and essential social support. However, a recent systematic review revealed several potentially limiting difficulties that this group experiences online and also suggested that there is a partial understanding of these difficulties as only difficulties associated with neurocognitive, but not sociocognitive, deficits were identified. Therefore, this study fills this knowledge gap and contributes to a more robust and fuller understanding of the difficulties this group experiences online. OBJECTIVE: The objective of this study was to identify the difficulties people with depression and anxiety experience when using the Web and the Web activities that are most associated with the experience of difficulties. METHODS: The study employed data triangulation using face-to-face semistructured interviews with 21 participants affected by depression and anxiety and a comparison group (7 participants) without mental disorders (study 1) as well as a persona-based expert online survey with 21 mental health practitioners (MHPs) who treated people with depression and anxiety (study 2). Framework analysis for both studies proceeded through 5 stages: (1) familiarization, (2) identifying a thematic framework, (3) indexing, (4) charting, and (5) mapping and interpretation. RESULTS: In study 1, 167 difficulties were identified from the experiences of participants in the depression and anxiety group were discussed within the context of 81 Web activities, services, and features. From these, 4 themes and 12 subthemes describing the difficulties people with depression and anxiety experienced online were identified. Difficulties relating to the subtheme lack of control over access and usage were the most common difficulties experienced by participants in the depression and anxiety group (19/21). Sixteen difficulties identified from the experiences of participants in the comparison group were discussed within the context of 11 Web activities, services, and features. Most participants in the comparison group (6/7) contributed to the subtheme describing difficulties with unexpected and irrelevant content. In study 2, researchers identified 3 themes and 10 subthemes that described the perceived difficulties people with depression and anxiety might experience online as reported by MHPs. Practitioners linked these difficulties with 22 common impairments, limitations in activities of daily life, and diagnostic criteria associated with depression and anxiety. CONCLUSIONS: People with depression and anxiety also experience difficulties when using the Web that are related to the sociocognitive deficits associated with their conditions. MHPs have a good awareness of the difficulties that people with depression and anxiety are likely to experience when using the Web. This investigation has contributed to a fuller understanding of these difficulties and provides innovative guidance on how to remove and reduce them for people with depression and anxiety when using the Web. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1007/978-3-319-21006-3_3.

Rethinking Disability.

Disability as a health outcome deserves more attention than it has so far received. With people living longer and the epidemiological transition from infectious to noncommunicable diseases as the major cause of health burden, we need to focus attention on disability - the non-fatal impact of heath conditions - over and above our concern for causes of mortality.With the first Global Burden of Disease study, WHO provided a metric that enabled the comparison of the impact of diseases, drawing on a model of disability that focused on decrements of health. This model has since been elaborated in the International Classification of Functioning, Disability and Health as being either a feature of the individual or arising out of the interaction between the individual's health condition and contextual factors. The basis of WHO's ongoing work is a set of principles: that disability is a universal human experience; that disability is not determined solely by the underlying health condition or predicated merely on the presence of specific health conditions; and finally, that disability lies on a continuum from no to complete disability. To determine whether interventions at individual or population levels are effective, an approach to disability measurement that allows for an appropriate and fair comparison across health conditions is needed. WHO has designed the Model Disability Survey (MDS) to collect information relevant to understand the lived experience of disability, including the person's capacity to perform tasks actions in daily life, their actual performance, the barriers and facilitators in the environment they experience, and their health conditions. As disability gains prominence within the development agenda in the United Nations Sustainable Development Goals, and the implementation of the United Nations Convention on the Rights of Persons with Disabilities, the MDS will provide the data to monitor the progress of countries on meeting their obligations.The lesson learned from WHO's activities is that disability is a universal human experience, in the sense that everyone can be placed on a continuum of functioning and either currently experiences or is vulnerable to experiencing disability over the course of their lives. This understanding of disability is the key to mainstreaming disability within the public discourse.