How to ensure equitable access to eye health for children with disabilities.

All children need access to good quality eye care, and this must include children with disabilities. Childhood disability is very common. The World Health Organization (WHO) estimates that there are at least 93 million children with disabilities worldwide, which equates to one in twenty children.1 Childhood disability is particularly common in low- and middle-income countries

Urbanization, ethnicity and cardiovascular risk in a population in transition in Nakuru, Kenya: a population-based survey.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death among older people in Africa. This study aimed to investigate the relationship of urbanization and ethnicity with CVD risk markers in Kenya. METHODS: A cross-sectional population-based survey was carried out in Nakuru Kenya in 2007-2008. 100 clusters of 50 people aged ≥ 50 years were selected by probability proportionate to size sampling. Households within clusters were selected through compact segment sampling. Participants were interviewed by nurses to collect socio-demographic and lifestyle information. Nurses measured blood pressure, height, weight and waist and hip circumference. A random finger-prick blood sample was taken to measure glucose and cholesterol levels.Hypertension was defined as systolic blood pressure (SBP) ≥ 140 mm Hg, or diastolic blood pressure (DBP) ≥ 90 mm Hg or current use of antihypertensive medication; Diabetes as reported current medication or diet control for diabetes or random blood glucose level ≥ 11.1 mmol/L; High cholesterol as random blood cholesterol level ≥ 5.2 mmol/L; and Obesity as Body Mass Index (BMI)≥ 30 kg/m2. RESULTS: 5010 eligible subjects were selected, of whom 4396 (88%) were examined. There was a high prevalence of hypertension (50.1%, 47.5-52.6%), obesity (13.0%, 11.7-14.5%), diabetes (6.6%, 5.6-7.7%) and high cholesterol (21.1%, 18.6-23.9). Hypertension, diabetes and obesity were more common in urban compared to rural groups and the elevated prevalence generally persisted after adjustment for socio-demographic, lifestyle, obesity and cardiovascular risk markers. There was also a higher prevalence of hypertension, obesity, diabetes and high cholesterol among Kikuyus compared to Kalenjins, even after multivariate adjustment. CVD risk markers were clustered both across the district and within individuals. Few people received treatment for hypertension (15%), while the majority of cases with diabetes received treatment (68%). CONCLUSIONS: CVD risk markers are common in Kenya, particularly in urban areas. Exploring differences in CVD risk markers between ethnic groups may help to elucidate the epidemiology of these conditions

Rapid assessment for prioritisation of trachoma control at community level in one district of the Kaolack Region, Senegal.

The objective of this study was to use a modified Lot Quality Assurance Sampling methodology to classify communities according to prevalence of active trachoma and to estimate the prevalence of trachoma and trichiasis in Nioro department, Kaolack Region, Senegal. A survey was conducted using two-stage cluster sampling to select 50 children aged 2-5 years in each of 33 clusters. In total 1,648 children were examined for active trachoma. Information on trachoma risk factors was collected through interviews with the mother or the household head of the child. Adults (>40 years) with trichiasis were identified through case finding. Nineteen clusters had a low prevalence of active trachoma in children aged 2-5 years (40%). The prevalence of active trachoma in children aged 2-5 years was 17.4% (95% CI 12.9-21.8%). Multivariate-adjusted predictors of active trachoma were: age, facial cleanliness, hygiene practices and keeping cattle in the household. The prevalence of trichiasis in adults aged over 40 years was 1.77% (95% CI 1.24-2.51), equating to 985 adults (95% CI 765-1250) with trichiasis in Nioro department. In conclusion, a survey using rapid methodology showed that trachoma is a problem of public significance in Nioro department, Senegal

Prevalence and predictors of refractive error and spectacle coverage in Nakuru, Kenya: a cross-sectional, population-based study.

A cross-sectional study was undertaken in Nakuru, Kenya to assess the prevalence of refractive error and the spectacle coverage in a population aged ≥50 years. Of the 5,010 subjects who were eligible, 4,414 underwent examination (response rate 88.1 %). LogMAR visual acuity was assessed in all participants and refractive error was measured in both eyes using a Topcon auto refractor RM8800. Detailed interviews were undertaken and ownership of spectacles was assessed. Refractive error was responsible for 51.7 % of overall visual impairment (VI), 85.3 % (n = 191) of subjects with mild VI, 42.7 % (n = 152) of subjects with moderate VI, 16.7 % (n = 3) of subjects with severe VI and no cases of blindness. Myopia was more common than hyperopia affecting 59.5 % of those with refractive error compared to 27.4 % for hyperopia. High myopia (+5.0 DS). Of those who needed distance spectacles (spectacle coverage), 25.5 % owned spectacles. In conclusion, the oldest, most poor and least educated are most likely to have no spectacles and they should be specifically targeted when refractive services are put in place

Debate: can we achieve universal health coverage without a focus on disability?

BACKGROUND: The achievement of Universal Health Coverage (UHC) is a key aim of the global health agenda, and an important target of the Sustainable Development Goals. There is increasing recognition that some groups may fall behind in efforts to achieve UHC, including the 1 billion people globally living with disabilities. A fundamental question for debate is - can UHC be achieved without the inclusion of people with disabilities? MAIN TEXT: People with disabilities are more likely to experience poor health. They will therefore have greater need for general healthcare services, as well as rehabilitation and specialist services, related to their underlying impairment. People with disabilities also frequently face additional difficulties in accessing healthcare, incur greater costs when seeking healthcare and often report experiencing worse quality services than others. As a consequence of these different challenges, people with disabilities face specific and added difficulties across three dimensions of UHC: coverage, access to services needed, and at reasonable cost. A focus on people with disabilities is therefore essential to achieving UHC, particularly since they constitute 15% of the global population. To ensure the realisation of UHC is inclusive of and addresses the needs of people with disabilities, health systems need to adapt. A twin-tracked approach is recommended, which means that there is a focus on including people with disabilities in mainstream services, as well as targeting them with specific services needed. There also must be efforts to improve the quality of services (e.g. through healthcare staff training) and enhance cost protection for people with disabilities (e.g. through social protection). A key challenge to changing UHC strategies to be more inclusive is the lack of evidence on what is needed and works, and more research is needed urgently on this topic. CONCLUSIONS: It will be difficult to achieve UHC without a focus on people with disabilities. Changes made to improve coverage for people with disabilities will likely benefit a wider group, including older people, ethnic minorities, and people with short-term functional difficulties. Disability-inclusive strategies will therefore improve health system equity and ensure that we "Leave no one behind" as we move towards UHC

A Systematic Review of Access to Rehabilitation for People with Disabilities in Low- and Middle-Income Countries.

Rehabilitation seeks to optimize functioning of people with impairments and includes a range of specific health services-diagnosis, treatment, surgery, assistive devices, and therapy. Evidence on access to rehabilitation services for people with disabilities in low- and middle-income countries (LMICs) is limited. A systematic review was conducted to examine this in depth. In February 2017, six databases were searched for studies measuring access to rehabilitation among people with disabilities in LMICs. Eligible measures of access to rehabilitation included: use of assistive devices, use of specialist health services, and adherence to treatment. Two reviewers independently screened titles, abstracts, and full texts. Data was extracted by one reviewer and checked by a second. Of 13,048 screened studies, 77 were eligible for inclusion. These covered a broad geographic area. 17% of studies measured access to hearing-specific services; 22% vision-specific; 31% physical impairment-specific; and 44% measured access to mental impairment-specific services. A further 35% measured access to services for any disability. A diverse range of measures of disability and access were used across studies making comparability difficult. However, there was some evidence that access to rehabilitation is low among people with disabilities. No clear patterns were seen in access by equity measures such as age, locality, socioeconomic status, or country income group due to the limited number of studies measuring these indicators, and the range of measures used. Access to rehabilitation services was highly variable and poorly measured within the studies in the review, but generally shown to be low. Far better metrics are needed, including through clinical assessment, before we have a true appreciation of the population level need for and coverage of these services

Protocol for a randomised controlled trial to evaluate the effectiveness of the 'Care for Stroke' intervention in India: a smartphone-enabled, carer-supported, educational intervention for management of disabilities following stroke.

INTRODUCTION: The rising prevalence of stroke and stroke-related disability witnessed globally over the past decades may cause an overwhelming demand for rehabilitation services. This situation is of concern for low-income and middle-income countries like India where the resources for rehabilitation are often limited. Recently, a smartphone-enabled carer-supported educational intervention for management of physical disabilities following stroke was developed in India. It was found to be feasible and acceptable, but evidence of effectiveness is lacking. Hence, as a step forward, this study intends to evaluate clinical effectiveness of the intervention through a randomised controlled trial. METHODS: The objective of the study is to evaluate whether the 'Care for Stroke' intervention is clinically and cost-effective for the reduction of dependency in activities of daily living among stroke survivors in an Indian setting. This study is designed as a randomised controlled trial comparing people who received the intervention to those receiving standard care. The trial will be pragmatic and outcome assessor-blinded. The primary outcome for the study is dependency in daily living measured by the Modified Rankin Scale (MRS). A total of 266 adult stroke survivors who fulfil the eligibility criteria will be randomised to receive either 'Care for Stroke' intervention or standard treatment and will be followed up for 6 weeks. The main analyses will compare participants allocated to the 'Care for Stroke' intervention versus those allocated to the standard treatment group on an 'intention-to-treat' basis, irrespective of whether the participants received the treatment allocated or not. The dichotomised MRS scores (0-3 and 4-6) in both the groups will be used to calculate the effect estimates with a measure of precision (95% CI) and presented in the results of the trial. ETHICS AND DISSEMINATION: The Indian Institute of Public Health-Hyderabad/Public Health Foundation of India - Independent Institutional Ethics Committee and the Ethics Committee of the London School of HygieneandTropical Medicine. Dissemination will be through peer-reviewed publications. TRIAL REGISTRATION NUMBER: Clinical Trial Registry of India CTRI/2017/07/009014

Neglected tropical diseases and disability-what is the link?

Neglected tropical diseases (NTDs) are a diverse group of infectious conditions that vary in their epidemiology, impact and control. They are among the most common conditions globally, affecting approximately one billion people. Many NTDs have long-term consequences, such as visual and physical impairments. As a result, people with NTDs may have difficulties in carrying out activities or participating in society-in other words, NTDs can cause disabilities. Additionally, NTDs are often strongly linked to stigma and can have mental health consequences. It is therefore important to incorporate rehabilitation within NTD programmes. Rehabilitation can be conceptualized narrowly in terms of the provision of clinical services (e.g. physiotherapy and assistive devices) or, more broadly, including efforts to improve employment, overcome stigma and enhance social participation of people with disabilities. Approximately 15% of the global population has a disability, and this large group must be considered when designing NTD programmes. Improving the inclusion of people with disabilities may require adaptations to NTD programmes, such as making them physically accessible or training staff about disability awareness. Without incorporating disability within NTD programmes, the quality of life of people with NTDs will suffer and global targets for elimination and management of NTDs will not be met

SDGs, Inclusive Health and the Path to Universal Health Coverage

The Sustainable Development Goals (SDGs) are a set of goals designed to improve the social, economic and well-being of all, while maintaining global and environmental sustainability. Health is one of the 17 goals, and focuses not only on addressing morbidity and mortality, but also on improving access to healthcare services for all through Universal Health Coverage (UHC). While disability is not specifically mentioned in this goal, a focus on people with disabilities is important given the inclusive nature of the SDGs and the fact that people with disabilities make up the largest minority group in the world. This paper aims to critically consider what the health goal could mean for people with disabilities and advocates for inclusive health. It discusses the complex relationship between disability and health, and why people with disabilities are more vulnerable to poor health are discussed, and then considers factors that impact access to quality healthcare for people with disabilities and how these impact on the achievement of the targets in SDG Health Goal and the main principles of UHC. The paper argues that developing an inclusive approach to healthcare will not only improve achieving good health for all, but is also important since experiencing poor health may reduce quality of life and participation (e.g. in education, employment or community activities). Poor quality of life and participation can exacerbate disability, poverty and exclusion in addition to increasing suffering, morbidity and early mortality. The paper concludes that an inclusive UHC will not only fulfil the fundamental rights of people with disabilities to health and rehabilitation, as emphasized within the UN Convention on the Rights of Persons with Disabilities, but also contribute to the achievement of the SDGs