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

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

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

Integration measurement and its applications in low- and middle-income country health systems: a scoping review.

BACKGROUND: Despite growing interest in and commitment to integration, or integrated care, the concept is ill-defined and the resulting evidence base fragmented, particularly in low- and middle-income countries (LMICs). Underlying this challenge is a lack of coherent approaches to measure the extent of integration and how this influences desired outcomes. The aim of this scoping review is to identify measurement approaches for integration in LMICs and map them for future use. METHODS: Arksey and O'Malley's framework for scoping reviews was followed. We conducted a systematic search of peer-reviewed literature measuring integration in LMICs across three databases and screened identified papers by predetermined inclusion and exclusion criteria. A modified version of the Rainbow Model for Integrated Care guided charting and analysis of the data. RESULTS: We included 99 studies. Studies were concentrated in the Africa region and most frequently focused on the integration of HIV care with other services. A range of definitions and methods were identified, with no single approach for the measurement of integration dominating the literature. Measurement of clinical integration was the most common, with indicators focused on measuring receipt of two or more services provided at a single point of time. Organizational and professional integration indicators were focused on inter- and intra-organizational communication, collaboration, coordination, and continuity of care, while functional integration measured common information systems or patient records. Gaps were identified in measuring systems and normative integration. Few tools were validated or publicly available for future use. CONCLUSION: We identified a wide range of recent approaches used to measure integration in LMICs. Our findings underscore continued challenges with lack of conceptual cohesion and fragmentation which limits how integration is understood in practice.

Improving access to prosthetic services in Western Nepal: a local stakeholder perspective.

PURPOSE: Evidence of effective strategies to improve access to assistive technology (AT) like prostheses is limited, especially in rural and remote areas of low- and middle-income countries where unmet needs are the greatest. This study aimed to identify barriers and facilitators to accessing prosthetic services in rural areas of western Nepal and explore strategies to improve access from the perspective of local stakeholders. METHOD: Semi-structured interviews were conducted with 13 service providers and consumers. Barriers and facilitators of access were highlighted and potential solutions to overcome access barriers were explored using thematic analysis of transcripts. RESULTS: Six themes concerning barriers and facilitators arose: awareness and literacy of prosthetic services, attitudes and belief systems, financial supports, geographical access, health system and referral processes, as well as service provider capacity and regulation. Six themes regarding potential solutions were also identified: awareness campaigns, procurement pathways, referral pathways, subsidised and shared costs of AT, professional support networks and development opportunities, as well as task shifting and sharing. CONCLUSIONS: While facilitating interventions support access to prosthetic services, they remain insufficient to overcome several barriers that continue to inhibit this access. Nevertheless, real opportunities to alleviate barriers and address the unmet need exist and must be explored.Implications For RehabilitationIt is advised that rehabilitation professionals, particularly those delivering prosthetic services in rural and remote settings of Nepal, consider piloting alternative service delivery strategies which utilise resources accessible to them in order to overcome several existing barriers to AT access e.g., task shifting.Rehabilitation professionals in Nepal have the opportunity to support others working in low-resources settings to expand professional development opportunities through online and digital platforms.Gathering and sharing data on the current state of prosthetic and AT service delivery within Nepal is highly valuable to the development of the prosthetic rehabilitation profession and ultimately equity in access to appropriate AT.Proposed interventions identified within this study can potentially serve to guide stakeholders in rural and remote settings of other LMICs in developing strategies to overcome barriers to AT access suitable to their context.

Measuring Self-Reported Access to Assistive Technology Using the WHO Rapid Assistive Technology Assessment (rATA) Questionnaire: Protocol for a Multi-Country Study.

In 2018, the World Health Assembly adopted a resolution on improving access to assistive technology (AT), and mandated the WHO to prepare a global report on assistive technology based on the best available evidence and international experience. As limited data on access to AT at country and global levels were available, there was a need to conduct representative population surveys in order to inform the development of the global report, national AT programs, and global initiatives. The objective of this protocol is to describe a multi-country study of access to assistive technology in six self-reported areas: use, source, payer, satisfaction, unmet need, and barriers. In collaboration with WHO Regional and Country offices, Member States, and other stakeholders, the Assistive Technology Access team in WHO coordinates the study. Data are collected through household surveys using the rapid Assistive Technology Assessment (rATA) questionnaire. Findings from the surveys will be published in the global report.

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

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

A Synthesis of Findings from 'Rapid Assessments' of Disability and the COVID-19 Pandemic: Implications for Response and Disability-Inclusive Data Collection.

INTRODUCTION: People with disabilities are disproportionately impacted by disasters, including health emergencies, and responses are not always inclusive or accessible. Disability-inclusive response and recovery efforts require rapid, contextually relevant data, but little was known about either the experience of people with disabilities in the first phase of the COVID-19 pandemic, or how rapid needs assessments were conducted. METHODS: We reviewed the available results from rapid assessments of impacts of COVID-19 on people with disabilities in low- and middle-income countries in Asia and the Pacific. Rapid assessment methods and questions were examined to describe the current approaches and synthesise results. RESULTS: Seventeen surveys met the inclusion criteria. The findings suggest that people with disabilities experienced less access to health, education, and social services and increased violence. The most rapid assessments were conducted by or with disabled person's organisations (DPOs). The rapid assessment methods were varied, resulting in heterogeneous data between contexts. Efforts to standardise data collection in disability surveys are not reflected in practice. CONCLUSIONS: Persons with disabilities were disproportionately impacted by the 'first wave' of the COVID-19 pandemic. Despite complex implementation challenges and methodological limitations, persons with disabilities have led efforts to provide evidence to inform disability-inclusive pandemic responses.

Compliance with standards of practice for health-related rehabilitation in low and middle-income settings: development and implementation of a novel scoring method.

Purpose: To (A) develop a method for measuring compliance with standards, and (B) implementation of the method in 12 rehabilitation centers in six low and middle-income countries (LMICs). Methods: In part A, existing standards were compiled and operationalized into scores, organized into 5 'scorecards' and 15 'sub-scorecards', then tested and refined in an iterative process. In part B, 12 rehabilitation centers in 6 countries implemented the standards using the new method, revealing relative performance between centers, and across different standards. Internal consistency of scores within domains was computed using Chronbach's alpha. Results: A standardized method for scoring compliance with standards for rehabilitation was developed. The method evaluated compliance with standards in five domains of practice: user focused approach, service outputs, finances, staff, and general management. Multiple standards within domains were strongly related, with Chronbach's alpha >0.80 for all but the equipment and supplies domain. Overall, in the 12 rehabilitation centers examined, 36% of standards were met or exceeded. Compliance within each scoring domain was 56% (user-focused approach), 38% (service outputs), 27% (financial management), 30% (staff management), and 33% (general management). Two out of 12 (17%) of centers met more than two-thirds of the standards, 3 (25%) met more than one-third of standards, while the remaining 7 (58%) met less than one-third of standards. Conclusions: A new, standardized method for measuring performance of rehabilitation services in LMICs was developed. The method examines standards in five rehabilitation practice domains, and can be used to understand barriers to quality performance, particularly in resource-constrained settings. Implementation of the method demonstrated that current compliance with standards is modest. Ongoing interest in new standards for rehabilitation practice should be accompanied by measures to ensure they are used to strengthen quality in an emerging rehabilitation sector. Implications for rehabilitation We developed a method for measuring compliance with standards for rehabilitation, and implemented the method in 12 rehabilitation centers in low and middle income countries. We demonstrate modest compliance with an adapted list of known standards of practice. New standards, scoring methods and evidence of current performance may assist service providers and policy makers to implement standards, and methods to strengthen rehabilitation services. Modest compliance with current standards suggest new emphasis on quality performance of health-related rehabilitation is needed New emphasis on standards for rehabilitation should be accompanied by consideration of how performance against those standards can be measured and improved.

Unmet Needs and Use of Assistive Products in Two Districts of Bangladesh: Findings from a Household Survey.

Access to assistive products (AP) is an under-researched public health issue. Using an adaptation of a draft World Health Organization tool-the 'Assistive Technology Assessment-Needs (ATA-N)' for measuring unmet needs and use of AP, we aimed to understand characteristics of AP users, self-reported needs and unmet needs for AP, and current access patterns in Bangladesh. The ATA-N was incorporated in a Rapid Assessment of Disability (RAD), a population-based survey to estimate prevalence and correlates of disability. In each of two unions of Kurigram and Narsingdi districts, 60 clusters of 50 people each aged two years and older were selected using a two-staged cluster random sampling process, of whom, 4250 (59% Female; 41% Male) were adults, including 333 using AP. We estimate 7.1% of the studied population used any AP. AP use is positively associated with age and self-reported functional difficulty. The proportion of people using AP is higher for mobility than for sensory and cognitive difficulties. Of all people with any functional difficulty, 71% self-reported an unmet need for AP. Most products were home or self-made, at low cost, but provided benefits. Needs and unmet needs for AP are high, especially for people with greater functional difficulties. Assessing unmet needs for AP revealed important barriers to scale that can inform policy and practice.