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.

WHO Functioning and Disability Disaggregation (FDD11) tool: a reliable approach for disaggregating data by disability.

BACKGROUND: There is a global scarcity of good quality disability data, which has contributed to a lack of political will to address the challenges that persons with disabilities face. The current paper proposes a way forward to overcome this gap by demonstrating the psychometric properties of the World Health Organization Functioning and Disability Disaggregation Tool (FDD11) - a brief disability disaggregation instrument that countries can use. RESULTS: The study demonstrated that FDD11 is a valid and reliable tool. Unidimensionality of the scale produced by each calibration was supported by the factor analysis performed. The analysis indicated good fit of the items, and targeting of the items was deemed to be sufficient. The person separation index was 0.82, indicating good reliability of the final scale. CONCLUSION: FDD11 provides a good opportunity to researchers and governments to capture good quality disability data and to disaggregate existing data by disability. The tool can facilitate low- and middle-income countries in their efforts to develop evidenced-based policies to address any barriers faced by persons with disabilities, to monitor the implementation of the Convention on the Rights of Persons with Disabilities and the Sustainable Development Goals, and to take stock of the challenges that still remain.

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.

A scoping review of measurement of violence against women and disability.

INTRODUCTION: Existing evidence indicates that prevalence of violence against women with disability is elevated compared to women without disability. We conducted a scoping review with a focus on measurement to assess the forms of measurement and study design utilized to explore the intersection of violence against women with disabilities, and to identify strengths and limitations in current approaches to measuring violence against women with disabilities. This scoping review is designed to inform current debates and discussions regarding how to generate evidence concerning violence against women with disabilities. METHODS AND RESULTS: We conducted systematic searches of the following databases: PubMed, PsycINFO, Embase, CINAHL, PILOTS, ERIC, Social Work Abstracts, International Bibliography of the Social Sciences, Social Services Abstracts, ProQuest Criminal Justice, and Dissertations & Theses Global, and conducted structured searches of national statistics and surveys and grey literature available on-line. We identified 174 manuscripts or reports for inclusion. n = 113 manuscripts or reports utilized acts-specific measurement of violence. In terms of measurement of disability, we found that amongst the included manuscripts and reports, n = 75 utilized measures of functioning limitations (n = 20 of these were Washington Group questions), n = 15 utilized a single question approach and n = 67 defined participants in the research as having a disability based on a diagnosis or self-report of a health condition or impairment. DISCUSSION: This scoping review provides a comprehensive overview of measurement of violence against women with disabilities and measurement of violence within disability-focused research. We identified several important gaps in the evidence, including lack of sex and disability disaggregation, limited evidence concerning adaptation of data collection methods to ensure accessibility of research activities for women with disabilities, and limited evidence concerning differential relationships between types of disability and violence exposure. This scoping review provides directions for sub-analyses of the included studies and further research to address gaps in evidence.

Generating comprehensive functioning and disability data worldwide: development process, data analyses strategy and reliability of the WHO and World Bank Model Disability Survey.

BACKGROUND: Data on functioning and disability collected at population level is essential to complement mortality and morbidity, to estimate rehabilitation needs of countries and regions and to monitor the Convention on the Rights of Persons with Disabilities (CRPD) and the Sustainable Development Goals (SDGs). The objective of this paper is to briefly report the development process of the WHO Model Disability Survey, its data analysis strategy as well as its reliability and ability to measure low to high levels of functioning and disability across countries. METHODS: The development process is described in detail, and a secondary analysis using Rasch methods is conducted to report reliability and targeting using data from eight national and two regional implementations of the survey. RESULTS: The currently available versions of the Model Disability Survey are presented. The survey has good to very good internal reliability and good targeting in all included countries. CONCLUSION: The participatory and evidence-based development, consideration of the expertise of stakeholders, the availability of previously developed ICF-based surveys, and WHO tools targeting functioning and disability are reflected in its good to very good psychometric properties. The survey has been implemented to date in Afghanistan, Cameroon, Chile, Costa Rica, India, Laos, Pakistan, Philippines, Sri Lanka, and Tajikistan, and is used to inform policy-making, to monitor the CRPD and SDGs and to plan the delivery of rehabilitation services.

Global return on investment and cost-effectiveness of WHO's HEAR interventions for hearing loss: a modelling study.

BACKGROUND: To address the growing prevalence of hearing loss, WHO has identified a compendium of key evidence-based ear and hearing care interventions to be included within countries' universal health coverage packages. To assess the cost-effectiveness of these interventions and their budgetary effect for countries, we aimed to analyse the investment required to scale up services from baseline to recommended levels, and the return to society for every US$1 invested in the compendium. METHODS: We did a modelling study using the proposed set of WHO interventions (summarised under the acronym HEAR: hearing screening and intervention for newborn babies and infants, pre-school and school-age children, older adults, and adults at higher risk of hearing loss; ear disease prevention and management; access to technologies such as hearing aids, cochlear implants, or hearing assistive technologies; and rehabilitation service provision), which span the life course and include screening and management of hearing loss and related ear diseases, costs and benefits for the national population cohorts of 172 countries. The return on investment was analysed for the period between 2020 and 2030 using three scenarios: a business-as-usual scenario, a progress scenario with a scale-up to 50% of recommended coverage, and an ambitious scenario with scale-up to 90% of recommended coverage. Using data for hearing loss burden from the Global Burden of Disease Study 2019, a transition model with three states (general population, diagnosed, and those who have died) was developed to model the national populations in countries. For the return-on-investment analysis, the monetary value of disability-adjusted life-years (DALYs) averted in addition to productivity gains were compared against the investment required in each scenario. FINDINGS: Scaling up ear and hearing care interventions to 90% requires an overall global investment of US$238·8 billion over 10 years. Over a 10-year period, this investment promises substantial health gains with more than 130 million DALYs averted. These gains translate to a monetary value of more than US$1·3 trillion. In addition, investment in hearing care will result in productivity benefits of more than US$2 trillion at the global level by 2030. Together, these benefits correspond to a return of nearly US$15 for every US$1 invested. INTERPRETATION: This is the first-ever global investment case for integrating ear and hearing care interventions in countries' universal health coverage services. The findings show the economic benefits of investing in this compendium and provide the basis for facilitating the increase of country's health budget for strengthening ear and hearing care services. FUNDING: None.

Measuring functional ability in healthy ageing: a nationwide cross-sectional survey in the Philippine older population.

OBJECTIVES: To analyse the empirical support of the functional ability concept in the healthy ageing framework developed by the WHO in a sample of the Philippine older population. According to this framework, environmental factors may enhance or hinder functional ability, which is the person's ability to do what they value, broadly represented by subjective well-being. Moreover, this network of relationships may be moderated by personal characteristics such as gender. DESIGN: Cross-sectional observational study. SETTING: Philippines, general population. PARTICIPANTS: Respondents of the 2016 National Disability Prevalence Survey/Model Functioning Survey aged 50+ (N=2825). PRIMARY AND SECONDARY OUTCOME MEASURES: Latent (unobserved) measures of functional ability, environmental factors (physical environmental factors and social network and support) and subjective well-being (positive affect, negative affect and evaluative well-being) were obtained from different items from the survey questionnaire using a SEM framework. RESULTS: We found that the relationship between environmental factors and the three components of subjective well-being considered in this study was partially explained by differences in functional ability. The portion of those effects accounted for by functional ability was comparatively larger for the physical than for the social environmental factors. We found no evidences of gender differences in this network of relationships. CONCLUSIONS: These findings suggest the relevance of functional ability at explaining the relationship between environmental factors and subjective well-being in older adults. Future studies may replicate these findings longitudinally and including other relevant measures as the person's objective level of intrinsic capacity.

Disability and COVID-19: ensuring no one is left behind.

The United Nations' Sustainable Development Agenda calls for targeted attention to the needs and rights of the most vulnerable populations to ensure a life of dignity and human security for all. In this paper, we argue that persons with disabilities are in a disproportionately vulnerable situation in public health emergencies. By using the example of Coronavirus disease 2019 (Covid-19), we explain why that is and call for the systematic consideration of the needs and rights of persons with disabilities during the response to the outbreak and during the recovery phase. Otherwise, equity will continue to be merely an aspiration during this COVID-19 emergency - as it will in future health emergencies.

Measuring functioning and disability using household surveys: metric properties of the brief version of the WHO and World Bank model disability survey.

BACKGROUND: The Model Disability Survey (MDS) is the current standard recommended by WHO to collect functioning and disability data. Answering calls from countries requesting a version to be implemented as a module that could be integrated into existing surveys and be used for monitoring disability trends and for data disaggregation, WHO developed the brief MDS. The objectives of this paper are to evaluate the metric properties of the disability metrics generated with the Brief MDS and the precision of the Brief MDS in comparison with the full MDS. RESULTS: The partial credit model, a unidimensional model for polytomous data from the Rasch family, was applied to evaluate psychometric properties using data from national MDS implementations in Chile (N = 12,265) and in Sri Lanka (N = 3000). The Brief MDS generates valid metrics for measuring disability, from the perspectives of capacity and performance, thereby achieving good levels of measurement precision in comparison with its full counterpart. CONCLUSION: Given the scarcity of valid functioning and disability modules for household surveys, the Brief MDS represents a milestone in disability measurement. The Brief MDS is currently used by countries to monitor disability trends over time, which is especially important to evaluate the impact of health policies and public health interventions, to disaggregate indicators of the Sustainable Development Goals, and to monitor the implementation of the UN Convention on the Rights of Persons with Disabilities (CRPD).

The First Global Physical Activity and Sedentary Behavior Guidelines for People Living With Disability.

BACKGROUND: The World Health Organization has released the first global public health guidelines on physical activity and sedentary behavior for people living with disability. This paper presents the guidelines, related processes, and evidence, and elaborates upon how the guidelines can support inclusive policy, practice, and research. METHODS: Methods were consistent with the World Health Organization protocols for developing guidelines. Systematic reviews of the evidence on physical activity for health for people living with disability were appraised, along with a consideration of the evidence used to inform the general 2020 World Health Organization guidelines. RESULTS: Evidence supported the development of recommendations for people living with disability, stressing that there are no major risks to engaging in physical activity appropriate to an individual's current activity level, health status, and physical function, and that the health benefits accrued generally outweigh the risks. They also emphasize the benefits of limiting sedentary behavior. CONCLUSIONS: The guidelines mark a positive step forward for disability inclusion, but considerable effort is needed to advance the agenda. This paper highlights key considerations for the implementation of the new recommendations for people living with disability, in line with the human rights agenda underpinning the Global Action Plan on Physical Activity 2018-2030 and allied policies.

Ear and Hearing Care Workforce: Current Status and its Implications.

OBJECTIVE: This study aimed to provide comprehensive global evidence on the availability of ear and hearing care (EHC) professionals and real-life examples that showcase the impact of workforce shortages on the workload faced by existing professionals. METHODS: Six sources of data were used to estimate availability of EHC workforce: a scoping literature review, World Health Organization (WHO) National Health Workforce Accounts platform, WHO Member States survey and regional consultations, hearing care organizations survey, and official government statistics. EHC professionals' workload undertaking common interventions was estimated through the WHO workload indicators of staffing need human resource management tool. RESULTS: With data on otolaryngologists from 138, audiologists from 102, speech and language therapists from 124, and teachers of the deaf from 86 countries, this study revealed large gaps in availability of EHC cadres. The majority of countries in the African region had less than one professional in each cadre per million in comparison with most European countries having up to 50 times higher densities. Workload indicators of staffing need calculations revealed the challenging workload faced by existing EHC professionals, with ratios between existing and required staff of 0.01-0.86. CONCLUSION: There is an enormous shortage of EHC professionals and urgent actions are needed to ensure sufficient and equitable access to services. Task sharing, a novel approach for improving access to hearing care alongside the development of new cadres, can be a vital strategy in overcoming the shortage of highly qualified providers in many settings, even in well-resourced health systems, to facilitate equitable access to required EHC services.

Methodological quality of clinical guidelines for universal newborn hearing screening.

AIM: To review existing guidelines for universal newborn hearing screening (UNHS), identify those that provide comprehensive and clear recommendations on the subject, and provide a brief overview. METHOD: A scoping literature review was performed in PubMed, the Guidelines International Network library, and national guideline databases to identify guidelines on newborn hearing screening developed or updated between 2004 and 2019. The quality of the guidelines was checked with the Checklist for the Quality Assessment of Guidelines (AGREE II). RESULTS: Six guidelines met all the inclusion criteria. All six were based on the 1-3-6 benchmark (screening completed by 1mo, audiological diagnosis by 3mo, enrolment in early intervention by 6mo). However, the guidelines varied in terms of their recommendations for the application of screening methods, role of health professionals in the screening process, and quality. Based on the AGREE II score, flexibility, adaptability, and foundation role for all other guidelines, the 2019 guidelines of the Joint Committee on Infant Hearing position statement were identified as the most appropriate to be recommended for adaptation by countries or programmes. INTERPRETATION: The diversity in the existing guidance can be confusing for countries and institutions that are planning to develop universal hearing screening programmes. As more countries and organizations develop their newborn hearing screening programmes, they will need examples to emulate. This review provides an evaluation of the quality, comprehensiveness, and applicability of existing clinical guidelines that can serve as a facilitator for countries, institutions, or organizations in their planning and implementation of a UNHS programme.

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.

Psychosocial interventions for violence exposed youth - A systematic review.

BACKGROUND: Violence exposure (direct, indirect, individual, structural) affects youth mental health. OBJECTIVE: We aimed to evaluate the effectiveness of psychosocial interventions in addressing the sequelae of violence exposure on youth (15-24 years old) and evaluate whether moderating factors impact intervention effectiveness. METHODS: We systematically searched eight databases and reference lists to retrieve any studies of psychosocial interventions addressing mental health among youth aged 15-25 exposed to violence. We assessed study risk of bias using an adapted version of the Downs and Black's Risk of Bias Scale. RESULTS: We identified n = 3077 studies. Sixteen articles representing 14 studies met were included. The studies assessed direct and indirect individual violence exposure at least once. We pooled the data from the 14 studies and evaluated the effects. We estimated an average effect of r+ = 0.57 (RCTs: 95 % CI 0.02-1.13; observational studies: 95 % CI 0.27-86) with some heterogeneity (RCTs: I2 = 78.03, longitudinal studies: I2 = 82.93). The most effective interventions are Cognitive Behavioral Therapy, and Exposure Therapy with an exposure focus. However, due to the small number of studies we are uncertain about benefits of interventions. CONCLUSIONS: No study assessed structural violence. Therefore, studies are needed to evaluate the effects of psychosocial interventions for youth exposed to direct, indirect, individual and structural violence.

Global and regional needs, unmet needs and access to hearing aids.

Objectives: This article aims to estimate the global and regional needs, unmet needs and access to hearing aids, as well as the morbidity that can be averted by their use.Design: The study was based on Global Burden of Disease data. Study sample: Hearing impaired individuals "in need" of a hearing aid were defined as those in the moderate, moderately severe, and severe categories.Results: Globally, 401.4 million people are 'in need' of hearing aids. The large majority (83%) of them do not use hearing aids, with higher levels being in some regions such as the African region (90%). Accounting for hearing aid coverage reduced morbidity by 14.6% (95% UI 13.1- 16) - from 25 million YLDs to 21.3 million YLDs. It was estimated that if every single prevalent case in need would use a hearing aid, the burden of disease in this population would be reduced from the untreated 25 million YLDs to 10.3 million YLDs - a reduction of 59%.Conclusions: Development of innovative low-cost technologies with effective service delivery models, policy and regulatory changes to improve access, and combatting the stigma and lack of awareness are some of the potential solutions to improve access to hearing aids.