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Access to education has been the central tenet of the Millennium Development Goal 2, which focused strongly on increasing enrolment yet failed to promote education quality and equity and address contextual complexities that sustain exclusion. As a consequence, many children are not learning. There is growing recognition that effective, efficient and equitable education for all will not be achieved without better accountability. The present paper details innovative methods for strengthening the learning process through better social accountability. The paper defines and tests in rural schools of Afghanistan and Pakistan a community-based system dynamics protocol using participatory group model building (GMB) techniques. We tested the protocol with two groups of teachers and one group of children, with the three produced causal loop diagrams highlighting factors that influence learning in the classroom from the perspectives of the participants. The sessions showed interest, engagement, quick mastery of how GMB methods work and clear understanding of how the current classroom system hinders learning for many students. Researchers found that large autonomy and initiative could be left to the workshop participants, keeping the facilitator's role to one of explaining the method and asking clarification about causal relations.

Evidence shows that stigma negatively influences the quality of life of persons with severe mental illness. Nonetheless, stigma towards mental illness is lower among persons with a lived experience of mental illness compared to the rest of the population. Understanding the association between stigma of mental illness and the mental status of individuals living in urban India and whether this association is moderated by demographic factors opens a new avenue for prevention of social exclusion. Persons diagnosed with schizophrenia, bipolar disorder, or severe unipolar depression (cases, n = 647) were recruited from among hospital patients in New Delhi between November 2011 and June 2012 and matched with non-psychiatric urban dwellers by age, sex, and location of residence (controls, n = 649). Propensity score matching with multivariable linear regression was used to test whether stigma towards mental illness, measured by a 13-item Stigma Questionnaire, differed between cases and controls. Cases reported significantly lower stigma scores than controls (b = -0.50, p < 0.0001). The strength of the association between mental illness and stigma was not affected after controlling for age, caste, sex, education, and employment status, while wealth marginally reduced the strength of the association. These findings suggest individuals with a lived experience of mental illness, in New Delhi, India, may be more tolerant towards mental illness and support the need to involve persons with lived experience in the development and implementation of health promotional campaigns and programs aimed at reducing stigma towards mental illness. [ABSTRACT FROM AUTHOR]

Education for children with disabilities in Afghanistan, particularly disabled girls, continues to lag behind despite laudable efforts of the Ministry of Education to promote universal access for all. The opportunity for education constitutes not just a means of achieving learning outcomes but also a space for social interaction, individual development and psychosocial support, which are paramount in Conflict-Affected Fragile States (CAFS). However, many persisting barriers still need to be overcome in Afghanistan to allow education for all and change negative attitudes towards education of children with disabilities. In this paper we argue that viewing education as a basic commodity, which is the widespread practice in CAFS, is not conducive to expanding human freedoms and capabilities. More specifically, through analyses of a national survey, we demonstrate that despite considerable resources, increasing access to education in Afghanistan has maintained processes of marginalisation of the already excluded. (Contains 3 notes, 4 tables and 5 figures.)

Humanitarian crises as a result of conflict are often characterised by failure of the social contract between the state and its citizens. For a variety of reasons, children with disabilities are often particularly vulnerable in time of humanitarian crisis. This paper draws on research undertaken by the authors in a series of countries affected by conflict and looks at how the politics and policies of such countries, and the humanitarian and development agencies working in them, continue to exclude children with disabilities from formal and informal education structures. It will be argued that this exclusion not only impedes progress on inclusive education, but also has wider implications as education programmes are often the conduit through which a number of additional child protection mechanisms are implemented. Children with disabilities who are not in the formal education system are therefore at risk not only of missing out on education opportunities, but are also excluded from critical child survival initiatives, thus increasing their vulnerability. (Contains 5 tables.)

In the early 1990s, UNESCO estimated that perhaps 97% of the world's 650 million disabled persons were unable to read or write, leading to significant efforts throughout the developing world to ensure that all children with disabilities attended school through "inclusive education" programmes. But what of the vast majority of persons with disabilities who now are adolescents or adults, well beyond the reach of classroom education, or the estimated 90% of disabled children who will still "age out" of the system before such inclusive education is available in their communities? In this paper, we review findings from a global literature search on literacy of adults with disability in developing countries which shows that there is currently little in international development, education, health or disability research policies or programmes that addresses this issue. On the basis of these findings we argue that while inclusive education efforts for children are important, more attention also needs to be directed to providing literacy skills to illiterate and marginally literate disabled adolescents and adults. A concerted effort to improve access to basic literacy and numeracy skills through both inclusion in general adult literacy programmes and disability-specific adult literacy programmes is urgently needed to reach the goals for education and poverty eradication established by the new United Nations Convention on the Rights of Persons with Disabilities and by the Millennium Development Goals.

Background: The 2006 United Nations Convention on the Rights of Persons with Disabilities states that the achievement of equal rights, empowerment and social inclusion of people with disabilities requires comprehensive rehabilitation services encompassing all components of the World Health Organization Community based rehabilitation (CBR) matrix: health, education, livelihood, social and empowerment. CBR programs specifically aim to deliver such comprehensive interventions. In the present study, we investigate the impact of a CBR program in Afghanistan on all these components. Methods: We enrolled 1861 newly recruited CBR participants with disabilities in the study, from 169 villages between July 2012 and December 2013 as well as 1132 controls with disabilities randomly selected through a two-stage process within 6000 households from 100 villages in the same provinces but outside the catchment area of the CBR program. We interviewed them again after one (midline) and two (end-line) years in the study. Using propensity score matching and difference in difference analysis, we estimated the impact of the CBR on outcomes of interest, namely mobility, activities of daily living, communication, participation in social and community life, emotional well-being and employment. Results: Three years on average into the CBR program, participants showed a significant and close to medium effect size reduction in emotional (Cohen's d = − 0.48, 95%CI[− 0.58--0.38]), and social participation challenges (Cohen's d = − 0.45, 95%CI[− 0.53−− 0.36]); small to medium effect size reduction in unemployment (Cohen's d = − 0.21, 95%CI[− 0.33--0.10]), activities of daily living (Cohen's d = − 0.26, 95%CI[− 0.35--0.18]), mobility (Cohen's d = − 0.36, 95%CI[− 0.44--.29]) and communication challenges (Cohen's d = − 0.38, 95%CI[− 0.46--0.3]). Conclusions: Our study indicates that a CBR program may provide positive rehabilitation outcomes for persons with disabilities even in a conflict context, and improve overall well-being of all participants with disabilities, whatever their impairment, individual characteristics and the CBR matrix components considered. Trial registration: ISRCTN, ISRCTN50214054. Registered August 5th 2020 - retrospectively registered [ABSTRACT FROM AUTHOR]

Recent study shows that 617 million children and adolescents–or six out of 10 globally- are not acquiring minimum levels in literacy and mathematics, indicating the magnitude of the learning acquisition problem. For children with disabilities in context of conflict, the situation is arguably even worse: the literature shows that they face difficulties to access the education system due to multiple barriers, and when they do access, they are not learning. Our paper examines if an active education policy promoting inclusion since 2005 in Afghanistan, a protracted crisis context, has been effective. Using two cross sectional household surveys carried out eight years apart (2005–2013), our study shows that access to school and literacy did not improve between 2005 and 2013 for children and youth with disabilities. Both access and literacy outcomes were worse for girls with disabilities, those with a mental, learning or associated disability and those living in household where the head was uneducated. Finally, odds of being mentally distressed significantly declined between 2005 and 2013 indicating that schools might play a protective role for children with disabilities in Afghanistan. Our findings suggest that a multilevel multi-pronged adaptation of the existing system to improve the learning experience and promote children’s resilience, particularly for children with disabilities, in conflict context such as Afghanistan, is required. [ABSTRACT FROM AUTHOR]

Background: Symptomatic Alzheimer's disease (AD) and depression independently increase crash risk. Additionally, depression is both a risk factor for and a consequence of AD.Objective: To examine whether a depression diagnosis, antidepressant use, and preclinical AD are associated with driving decline among cognitively normal older adults.Methods: Cognitively normal participants, age ≥65, were enrolled. Cox proportional hazards models evaluated whether a depression diagnosis, depressive symptoms (Geriatric Depression Scale), antidepressant use, cerebrospinal fluid (amyloid-β42 [Aβ42], tau, phosphorylated tau181 [ptau181]), and amyloid imaging biomarkers (Pittsburgh Compound B and Florbetapir) were associated with time to receiving a rating of marginal/fail on a road test. Age was adjusted for in all models.Results: Data were available from 131 participants with age ranging from 65.4 to 88.2 years and mean follow up of 2.4 years (SD = 1.0). A depression diagnosis was associated with a faster time to receiving a marginal/fail rating on a road test and antidepressant use (p = 0.024, HR = 2.62). Depression diagnosis and CSF and amyloid PET imaging biomarkers were associated with driving performance on the road test (p≤0.05, HR = 2.51-3.15). In the CSF ptau181 model, depression diagnosis (p = 0.031, HR = 2.51) and antidepressant use (p = 0.037, HR = 2.50) were statistically significant predictors. There were no interaction effects between depression diagnosis, antidepressant use, and biomarker groups. Depressive symptomology was not a statistically significant predictor of driving performance.Conclusions: While, as previously shown, preclinical AD alone predicts a faster time to receiving a marginal/fail rating, these results suggest that also having a diagnosis of depression accelerates the onset of driving problems in cognitively normal older adults. [ABSTRACT FROM AUTHOR]

Background: In the new Sustainable Development Goal 4, quality of education defined as equity and inclusion alongside traditional learning outcomes, has replaced the narrow goal of access to primary education stipulated in the Millennium Development Goal 2. Since 2000, considerable progress has been made towards improving access to school for children in India, yet questions remain regarding not just children with disabilities’ access and acquisition of basic learning skills, but also completion of learning cycles. Methods and findings: Between November, 2, 2011 and June 20th 2012, we interviewed 1294 households about activity limitations and functioning difficulties associated with a health problem among all family members using a validated screening instruments, as well as questions about access, retention and barriers to education. We found that vulnerable children, particularly children with disabilities are less likely to start school and more likely to drop out of school earlier and before completing their high school education than non-disabled children, showing that the learning process is not inclusive in practice. The gap is wider for girls, economically deprived children, or children from households where the head is uneducated. Conclusions: Firstly, in order to fill the existing knowledge gap on education of children with disabilities in line with SDG4, not only is there a necessity for relevant data with regards to learning outcomes, but also an urgent requirement for more innovative information pertaining to relational aspects of learning that reflect inclusion. Secondly, a stronger understanding of the implications of early assessment would further promote equity in education. Finally, research should tackle learning as a complex and dynamic phenomenon. Education needs to fulfil its instrumental value, but must also re-claim its intrinsic value that often gets watered down in the journey from policies to implementation. [ABSTRACT FROM AUTHOR]

Background: Afghanistan lacks suitable specialized mental healthcare services despite high prevalence of severe mental health disorders which are aggravated by the conflict and numerous daily stressors. Recent studies have shown that Afghans with mental illness are not only deprived of care but are vulnerable in many other ways. Innovative participatory approaches to the design of mental healthcare policies and programs are needed in such challenging context. Methods: We employed community based system dynamics to examine interactions between multiple factors and actors to examine the problem of persistently low service utilization for people with mental illness. Group model building sessions, designed based on a series of scripts and led by three facilitators, took place with NGO staff members in Mazar-I-Sharif in July 2014 and in Kabul in February 2015. Results: We identified major feedback loops that constitute a hypothesis of how system components interact to generate a persistently low rate of service utilization by people with mental illness. In particular, we found that the interaction of the combined burdens of poverty and cost of treatment interact with cultural and social stigmatizing beliefs, in the context of limited clinical or other treatment support, to perpetuate low access to care for people with mental disorders. These findings indicate that the introduction of mental healthcare services alone will not be sufficient to meaningfully improve the condition of individuals with mental illness if community stigma and poverty are not addressed concurrently. Conclusions: Our model highlights important factors that prevent persons with mental illness from accessing services. Our study demonstrates that group model building methods using community based system dynamics can provide an effective tool to elicit a common vision on a complex problem and identify shared potential strategies for intervention in a development and global health context. Its strength and originality is the leadership role played by the actors embedded within the system in describing the complex problem and suggesting interventions. [ABSTRACT FROM AUTHOR]

Background: Although 80% of persons with disabilities live in low and middle-income countries, there is still a lack of comprehensive, cross-culturally validated tools to identify persons facing activity limitations and functioning difficulties in these settings. In absence of such a tool, disability estimates vary considerably according to the methodology used, and policies are based on unreliable estimates. Methods and Findings: The Disability Screening Questionnaire composed of 27 items (DSQ-27) was initially designed by a group of international experts in survey development and disability in Afghanistan for a national survey. Items were selected based on major domains of activity limitations and functioning difficulties linked to an impairment as defined by the International Classification of Functioning, Disability and Health. Face, content and construct validity, as well as sensitivity and specificity were examined. Based on the results obtained, the tool was subsequently refined and expanded to 34 items, tested and validated in Darfur, Sudan. Internal consistency for the total DSQ-34 using a raw and standardized Cronbach’s Alpha and within each domain using a standardized Cronbach’s Alpha was examined in the Asian context (India and Nepal). Exploratory factor analysis (EFA) using principal axis factoring (PAF) evaluated the lowest number of factors to account for the common variance among the questions in the screen. Test-retest reliability was determined by calculating intraclass correlation (ICC) and inter-rater reliability by calculating the kappa statistic; results were checked using Bland-Altman plots. The DSQ-34 was further tested for standard error of measurement (SEM) and for the minimum detectable change (MDC). Good internal consistency was indicated by Cronbach’s Alpha of 0.83/0.82 for India and 0.76/0.78 for Nepal. We confirmed our assumption for EFA using the Kaiser-Meyer-Olkin measure of sampling well above the accepted cutoff of 0.40 for India (0.82) and Nepal (0.82). The criteria for Bartlett’s test of sphericity were also met for both India (< .001) and Nepal (< .001). Estimates of reliability from the two countries reached acceptable levels of ICC of 0.75 (p<0.001) for India of 0.77 for Nepal (p<0.001) and good strength of agreement for weighted kappa (respectively 0.77 and 0.79). The SEM/MDC was 0.80/2.22 for India and 0.96/2.66 for Nepal indicating a smaller amount of measurement error in the screen. Conclusions: In Nepal and India, the DSQ-34 shows strong psychometric properties that indicate that it effectively discriminates between persons with and without disabilities. This instrument can be used in association with other instruments for the purpose of comparing health outcomes of persons with and without disabilities in LMICs. [ABSTRACT FROM AUTHOR]

Although a growing body of research is exploring the links between disability and poverty, the evidence that persons with disabilities are more likely to be poor than their non-disabled counterpart remains scarce. The causal relationship between disability and poverty has most often been considered in terms of disparities in income or living conditions. However, some research strongly suggests that disability is associated with deprivation in a number of other dimensions. To date, no study has examined these associations using large scale surveys with a wide range of wellbeing dimensions and indicators using a multidimensional approach. The present paper presents findings of three multidimensional poverty measures based on 17 indicators of deprivation collected through large-scale household surveys in Morocco and Tunisia. These indicators cover a wide range of dimensions of poverty such as health, education, employment, material well-being, social participation, psychological well-being and physical security. Results confirm that persons with disabilities are poorer than non-disabled people in both countries. The study shows that persons with disabilities, particularly girls and women, rural residents, and those with intellectual, mental or multiple disabilities are particularly deprived of basic capabilities and functionings and that stigma plays a role in this social injustice. Civil society organizations should take the lead to promote awareness of social and emotional well-being of persons with disabilities. [ABSTRACT FROM PUBLISHER]

Objective: To assess the effect of experienced stigma on depth of multidimensional poverty of persons with severe mental illness (PSMI) in Delhi, India, controlling for gender, age and caste. Design: Matching case (hospital)--control (population) study. Setting: University Hospital (cases) and National Capital Region (controls), India. Participants: A case--control study was conducted from November 2011 to June 2012. 647 cases diagnosed with schizophrenia or affective disorders were recruited and 647 individuals of same age, sex and location of residence were matched as controls at a ratio of 1:2:1. Individuals who refused consent or provided incomplete interview were excluded. Main outcome measures: Higher risk of poverty due to stigma among PSMI. Results: 38.5% of PSMI compared with 22.2% of controls were found poor on six dimensions or more. The difference in multidimensional poverty index was 69% between groups with employment and income of the main contributors. Multidimensional poverty was strongly associated with stigma (OR 2.60, 95% CI 1.27 to 5.31), scheduled castes/scheduled tribes/other backward castes (2.39, 1.39 to 4.08), mental illness (2.07, 1.25 to 3.41) and female gender (1.87, 1.36 to 2.58). A significant interaction between stigma, mental illness and gender or caste indicates female PSMI or PSMI from 'lower castes' were more likely to be poor due to stigma than male controls (p<0.001) or controls from other castes (p<0.001). Conclusions: Public stigma and multidimensional poverty linked to SMI are pervasive and intertwined. In particular for low caste and women, it is a strong predictor of poverty. Exclusion from employment linked to negative attitudes and lack of income are the highest contributors to multidimensional poverty, increasing the burden for the family. Mental health professionals need to be aware of and address these issues. [ABSTRACT FROM AUTHOR]

This study examined the prevalence of mental distress among groups in Afghanistan considered to be at risk. Data were drawn from a representative cross-sectional disability survey carried out in Afghanistan including 5,130 households in 171 clusters throughout the 34 provinces of the country. The sample included 838 nondisabled control participants aged above 14, and 675 disabled participants. Results showed that various vulnerable groups (disabled people, the unemployed, the elderly, minority ethnic groups, as well as widowed, divorced or separated women) were at higher risk of experiencing mild to severe mental health problems. The adjusted odds ratio for war-related disability compared to nondisabled was 4.09 (95% confidence interval 2.09 to 7.99) for mild mental distress disorders, and 7.10 (3.45–14.5) and 14.14 (3.38–59.00) for moderate or severe mental distress disorders, respectively. Women with disabilities (whatever the cause of impairment) when compared with nondisabled men, as well as poorer segments of society compared to the richest, had a higher prevalence of mental health problems. Women with non-war-related disabilities compared with nondisabled men were respectively 3.35 (1.27–8.81) and 8.57 (3.03–24.1) times more likely to experience mild or moderate mental distress disorders. People who experience multiple vulnerabilities are more at risk of deteriorating mental health in conflict zones. The study shows that mental health, in times of war, is influenced by a combination of demographic and socioeconomic characteristics linked to social exclusion mechanisms that were in place before the conflict began and that are redefined in relation to the changing social, cultural, and economic contexts. Mental health policies and programmes must prioritise the most vulnerable segments of Afghan society. [ABSTRACT FROM PUBLISHER]

Education for children with disabilities in Afghanistan, particularly disabled girls, continues to lag behind despite laudable efforts of the Ministry of Education to promote universal access for all. The opportunity for education constitutes not just a means of achieving learning outcomes but also a space for social interaction, individual development and psychosocial support, which are paramount in Conflict-Affected Fragile States (CAFS). However, many persisting barriers still need to be overcome in Afghanistan to allow education for all and change negative attitudes towards education of children with disabilities. In this paper we argue that viewing education as a basic commodity, which is the widespread practice in CAFS, is not conducive to expanding human freedoms and capabilities. More specifically, through analyses of a national survey, we demonstrate that despite considerable resources, increasing access to education in Afghanistan has maintained processes of marginalisation of the already excluded. [ABSTRACT FROM PUBLISHER]

This paper examines the relationship between capabilities, well-being and the impact of development efforts in Afghanistan. Using data from a nationally representative survey, it is argued that very vulnerable groups maintain a positive perception of well-being by referring to collective values and practices. The data suggest that deprivation of individual basic capabilities does not systematically lead to a low perception of well-being if individuals have access to other capabilities such as love, care and participation in community affairs. Nevertheless, access to basic capabilities remains crucial in order to ensure that social norms and expectations cease to constitute constraints and become factors through which agency and empowerment are enhanced. The results also show the dangers of tackling inequalities by designing policies that target individuals isolated from the group. [ABSTRACT FROM PUBLISHER]

In the early 1990s, UNESCO estimated that perhaps 97% of the world's 650 million disabled persons were unable to read or write, leading to significant efforts throughout the developing world to ensure that all children with disabilities attended school through ‘inclusive education’ programmes. But what of the vast majority of persons with disabilities who now are adolescents or adults, well beyond the reach of classroom education, or the estimated 90% of disabled children who will still ‘age out’ of the system before such inclusive education is available in their communities? In this paper, we review findings from a global literature search on literacy of adults with disability in developing countries which shows that there is currently little in international development, education, health or disability research policies or programmes that addresses this issue. On the basis of these findings we argue that while inclusive education efforts for children are important, more attention also needs to be directed to providing literacy skills to illiterate and marginally literate disabled adolescents and adults. A concerted effort to improve access to basic literacy and numeracy skills through both inclusion in general adult literacy programmes and disability-specific adult literacy programmes is urgently needed to reach the goals for education and poverty eradication established by the new United Nations Convention on the Rights of Persons with Disabilities and by the Millennium Development Goals. [ABSTRACT FROM AUTHOR]

Humanitarian crises as a result of conflict are often characterised by failure of the social contract between the state and its citizens. For a variety of reasons, children with disabilities are often particularly vulnerable in time of humanitarian crisis. This paper draws on research undertaken by the authors in a series of countries affected by conflict and looks at how the politics and policies of such countries, and the humanitarian and development agencies working in them, continue to exclude children with disabilities from formal and informal education structures. It will be argued that this exclusion not only impedes progress on inclusive education, but also has wider implications as education programmes are often the conduit through which a number of additional child protection mechanisms are implemented. Children with disabilities who are not in the formal education system are therefore at risk not only of missing out on education opportunities, but are also excluded from critical child survival initiatives, thus increasing their vulnerability. [ABSTRACT FROM AUTHOR]

Cet article constitue une tentative d'analyse de certains manquements qui ont ralenti les efforts menés dans le champ du handicap en Afghanistan. Apres le passage en revue des initiatives récentes, l'article présente les éléments qui ont contribué à limiter leur impact. Le développement des services publics de base est particulièrement difficile dans les Etats fragiles. Afin de surmonter les insuffisances identifiées, les auteurs estiment que l'approche par les capabilités de Amartya Sen offre un cadre d'analyse approprié pour définir une politique du handicap et la mettre en œuvre. Bien que la définition du développement humain ait beaucoup évolué au cours de la dernière décennie, sa traduction dans les faits demeure insuffisante, sans aucun effet visible sur le processus d'élaboration des politiques publiques ni même en terme de bien-être. En s'appuyant sur l'exemple de l'enquête nationale sur le handicap en Afghanistan, les auteurs débattent du besoin de connaissances scientifiques ainsi que des défis posés par un travail de recherche fondé sur l'approche par les capabilités pour définir et mettre en œuvre une politique publique du handicap.European Journal of Development Research (2009) 21, 297-319. doi:10.1057/ejdr.2009.8 [ABSTRACT FROM AUTHOR]

Date Presented 05/04/19 OT research is virtually nonexistent in many lower-middle-income countries. In this study, researchers partnered with a community organization to explore a culturally grounded and relevant role for OT with families of children with Down syndrome in Kyrgyzstan. Primary Author and Speaker: Allison Burns Contributing Authors: Parul Bakhshi, Kathy Kniepmann, Lauren Milton [ABSTRACT FROM AUTHOR]

Abstract Climate change may be the most pressing existential threat to human health and wellbeing in the twenty first century. In this paper, the authors provide context and critique on barriers to climate action in the United States and other high-income countries, including the profit-driven approach to health, consumerism, and the climate change countermovement. The reciprocal connections between occupational engagement and climate damage are examined from a lens of collective and irresponsible occupations and subsequent accountability. The authors propose the United Nations’ Sustainable Development Goals as a basis for recommendations occupational therapy practitioners could implement within the priorities of adaptation, mitigation, and resilience. [ABSTRACT FROM AUTHOR]