Are current approaches for measuring access to clean water and sanitation inclusive of people with disabilities? Comparison of individual- and household-level access between people with and without disabilities in the Tanahun district of Nepal.

BACKGROUND: The critical importance of safe and affordable access to water, sanitation and hygiene (WASH) is highlighted in Goal 6 of the Sustainable Development Goals, which seeks to achieve universal and equitable access for all by 2030. However, people with disabilities-who comprise 15% of the global population-frequently face difficulties meeting their WASH needs. Unmet WASH needs amongst people with disabilities may not be captured through current approaches to tracking progress towards Goal 6, which focus on household- rather than individual-level access. OBJECTIVE: To evaluate access to safe water, sanitation and hygiene (WASH), at the individual- and household-level, amongst people with disabilities in the Tanahun district of Nepal. METHODS: A population-based survey of disability was conducted from August-October 2016 to evaluate access to improved water and sanitation facilities between households with members with disabilities (n = 198) and those without (n = 1,265) in the Tanahun district of Nepal. A nested case-control then compared individual-level access between cases aged 15 and above with disabilities (n = 192) and age-sex-location matched controls without disabilities (n = 189), using the newly developed 21-item "Quality of WASH Access" questionnaire. Multivariate regression was used to compare household- and individual-level indicators between people and households with and without disabilities. In-depth interviews with 18 people with disabilities and their caregivers was conducted to assess the acceptability and appropriateness of the "Quality of WASH Access" questionnaire. FINDINGS: There were no significant differences between households with and without members with disabilities in access to an improved sanitation facility or water source. However, at the individual-level, people with disabilities experienced significantly greater difficulties accessing water, sanitation and hygiene compared to people without disabilities (p<0.001 for all three scores). Amongst people with disabilities, water difficulty scores were associated with having a physical impairment and greater disability severity; sanitation difficulty scores were associated with lower socioeconomic status and physical or self-care limitations; and hygiene difficulty scores were positively associated with self-care limitations and lower socioeconomic status, and inversely associated with hearing impairments. Qualitative research found the "Quality of WASH Access" questionnaire was well understood by participants and captured many of the challenges they faced. Additional challenges not covered by the tool included: (1) time spent on WASH, (2) consistency of access, (3) sufficiency of access, and (4) dignity of access. CONCLUSION: People with disabilities face substantial challenges to meeting their WASH needs, particularly in using services autonomously, consistently, hygienically, with dignity and privacy, and without pain or fear of abuse. These challenges are not captured through household-level data, and so individual-level WASH access are needed to monitor progress towards universal WASH access. The Quality of WASH Access questionnaire may provide a useful data collection tool

Does disability increase the risk of poverty ‘in all its forms’? Comparing monetary and multidimensional poverty in Vietnam and Nepal

To meet the Sustainable Development Goals target of ending poverty “in all its forms”, it is critical to monitor progress towards poverty alleviation, including amongst people with disabilities. This research used data from a population-based nested case control studies (n=667) and compares monetary and multidimensional poverty levels amongst people with and without disabilities in the districts of Cam Le, Vietnam and Tanahun, Nepal. Overall, there were no significant differences in incidence of monetary poverty between people with and without disabilities. However, approximately half of people with disabilities were multidimensionally poor in both settings, twice as frequent as compared to people without disabilities. Amongst people with disabilities, multidimensional poverty was associated with having a functional limitation affecting cognition and self-care, disability severity and younger age. The high incidence of multidimensional poverty amongst people with disabilities even in the absence of monetary poverty indicates a need for social protection and other interventions

Disability among Older People: Analysis of Data from Disability Surveys in Six Low- and Middle-Income Countries

This analysis of surveys from six low- and middle-income countries (LMICs) aimed to (i) estimate the prevalence of disability among older adults and (ii) compare experiences and participation in key life areas among older people with and without disabilities which may show vulnerability during the COVID-19 pandemic. Data were analysed from district-level or national surveys in Cameroon, Guatemala, Haiti, India, Nepal and the Maldives, which across the six databases totalled 3499 participants aged 60 years and above including 691 people with disabilities. Disability was common among adults 60+, ranging from 9.7% (8.0–11.8) in Nepal to 39.2% in India (95% CI 34.1–44.5%). Mobility was the most commonly reported functional difficulty. In each setting, older people with disabilities were significantly less likely to be working and reported greater participation restrictions and environmental barriers in key life areas compared to people in the same age categories without disabilities (p < 0.05). Disability is common in this population, and older people with disabilities may have greater difficulties participating in COVID-19 responses and have high economic vulnerabilities. It is imperative to prioritise the needs of older people with disabilities in the COVID-19 pandemic, including ensuring accessibility of both health services and the community in genera

Interrogating and Reflecting on Disability Prevalence Data Collected Using the Washington Group Tools: Results from Population-Based Surveys in Cameroon, Guatemala, India, Maldives, Nepal, Turkey and Vanuatu.

The Washington Group (WG) tools capture self-reported functional limitations, ranging from 6 domains in the Short Set (SS) to 11 in the Extended Set (ESF). Prevalence estimates can vary considerably on account of differences between modules and the different applications of them. We compare prevalence estimates by WG module, threshold, application and domain to explore these nuances and consider whether alternative combinations of questions may be valuable in reduced sets. We conducted secondary analyses of seven population-based surveys (analyses restricted to adults 18+) in Low- and Middle-Income Countries that used the WG tools. The prevalence estimates using the SS standard threshold (a lot of difficulty or higher in one or more domain) varied between 3.2% (95% Confidence Interval 2.9-3.6) in Vanuatu to 14.1% (12.2-16.2) in Turkey. The prevalence was higher using the ESF than the SS, and much higher (5 to 10-fold) using a wider threshold of "some" or greater difficulty. Two of the SS domains (communication, self-care) identified few additional individuals with functional limitations. An alternative SS replacing these domains with the psychosocial domains of anxiety and depression would identify more participants with functional limitations for the same number of items. The WG tools are valuable for collecting harmonised population data on disability. It is important that the impact on prevalence of use of different modules, thresholds and applications is recognised. An alternative SS may capture a greater proportion of people with functional domains without increasing the number of items

Abortion Clients of a Public-sector Clinic and a Non-governmental Organization Clinic in Nepal

This paper investigates similarities and differences between abortion clients of a public-sector clinic and a non-governmental organization (NGO) clinic in Nepal. In 2010, a survey of 1,172 women was conducted in two highly-attended abortion clinics in Kathmandu—one public-sector clinic and another operated by an NGO. Data on the sociodemographic characteristics of clients, their fertility preferences, and use of contraceptives were analyzed. Similarities and differences between the two groups of clients were examined by either chi-square or t-test. The clients of the two clinics were similar with respect to age (27.3±5.7 years), education (26.5% had no education), and number of living children (1.88±1.08). They differed with regard to contraceptive practice, the circumstances resulting in unintended pregnancy, and future fertility preferences. Just over 50% clients of the public and 35% clients of the NGO clinic reported use of contraceptives surrounding the time of unintended pregnancy. The groups also differed in the contraceptive methods used and in reasons for not using any method. The NGO clinic contributed principally to expanding the availability of and access to abortion services

Gaps in access and school attainments among people with and without disabilities: a case from Nepal

Aim: Many children with disabilities in low- and middle-income countries do not attend school and one-third are out of school. In order to ensure that education is for all including children with disabilities, research is needed on barriers to schooling to identify targets for intervention. The study will examine the determinants of school achievement among persons with and without disabilities as well as among each type of impairment. Methods: The study will utilize data from a recent national, representative household survey on living conditions among persons with and without disabilities. The individual level data used in this article comprise 2123 persons with and 2000 persons without disabilities. Results: The results show that an alarmingly high proportion of persons in Nepal have not accessed formal education, with access being significantly lower among persons with disabilities. While the results may be influenced by the assumed relationship between disability and poverty, results from analyzing the cross-sectional data cannot be conclusive on the influence of disability vs. poverty in determining differences in access and school attainments. Increased environmental barriers, higher age, rural location, and increased levels of disability were found to be associated with lower educational achievement. Pronounced differences in access to education were found between impairment types, with individuals with physical impairments achieving the highest level and individuals with multiple impairments, hearing and mental impairments achieving lowest. Conclusions: It is necessary both to strengthen the entire educational sector and at the same time allocate resources that will ensure that all children are on board and that particular efforts are implemented to cater for those who are easily side-lined

Access to Social Protection Among People with Disabilities:Mixed Methods Research from Tanahun, Nepal

While people with disabilities are often targeted as key beneficiaries of social protection, there is little evidence available on their participation in existing programmes. This study uses mixed methods to explore access to disability-targeted and non-targeted social protection programmes in Nepal, particularly the District of Tanahun. In total, 31% of people with disabilities had Disability Identification Cards, which entitles them to a range of different social protection benefits depending on the card level, including disability-targeted social assistance (received by 13% of people with disabilities). Overall, 37% of people with disabilities received social assistance, which was higher than for people without disabilities (21%). The most commonly accessed form of social assistance was the Old Age Allowance, which had universally high coverage amongst both people with and without disabilities. Uptake of disability-targeted social protection entitlements other than social assistance (e.g. scholarships, discounted transportation and health services) was generally low. Factors impacting upon access included the geographic and financial accessibility of the application process, procedures for determining eligibility and compliance of service providers

Physical activity, time use, and food intakes of rural households in Ghana, India, and Nepal 2017-2018

This research aimed at developing methods and protocols for generating reliable human energy expenditure profiles that can be used in a variety of agricultural settings in developing countries. The research was carried out in Ghana, India, and Nepal and it developed a protocol in which respondents’ physical activity data (accelerometry data) can be integrated with time use and food intake data. The data and methodology developed through this research provide insights into (1) the energy expenditure and time allocation dimension of agricultural practices and innovations and (2) the gender-differentiated intra-household labour and time allocation associated with these practices and innovations. Such insights are critical for the design of nutritionally-sensitive agricultural interventions