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Purpose: People with intellectual disabilities are deeply affected by health inequity, which is also reflected in their access to and use of assistive technology (AT) which could benefit them. Including the perspectives of adults with intellectual disabilities and their caregivers, together with the views of local health professionals, suppliers of AT and policy-makers, this paper aims to provide an overview of factors influencing access to AT and its use by people with intellectual disabilities in Bangalore, a southern region of India. Method: Face-to-face interviews were conducted with 15 adults with intellectual disabilities (ranging from mild to profound) and their caregivers, and with 16 providers of assistive technology. This helped to gain insight into the current use, needs, knowledge, awareness, access, customisation, funding, follow-up, social inclusion, stigma and policies around assistive technology and intellectual disability. Results: Access to assistive technology was facilitated by community fieldworkers and services to reach out and identify people with intellectual disability. Important barriers were stigma, and lack of knowledge and awareness among parents. Factors related to continued use were the substantial dependence on the care system to use assistive technology, and the importance of AT training and instructions for the user and the care system. Conclusion and Implications: The barriers and facilitators related to assistive technology for people with intellectual disability differ from other populations in need. The findings of this study can be used to inform and adjust country policies and frameworks whose aim is to improve access to AT and enhance the participation of people with intellectual disabilities within their communities.

This study aimed to investigate the relationship between death anxiety levels at pre-exposure to human donor remains, post-exposure self-worth, and post-exposure death anxiety levels, among a sample of Irish medical students. A multi-wave prospective study was conducted, using questionnaires administered at six time-points. Path analysis was used to investigate the effect of pre-exposure death anxiety levels and post-exposure self-worth on post-exposure death anxiety levels. Baseline death anxiety was found to predict post-exposure death anxiety. Furthermore, self-worth at one month of exposure was found to mediate the relationship between pre-exposure death anxiety levels and death anxiety levels at six months.

Objective: Emerging evidence indicates that the mental health consequences of COVID-19 may not be as deleterious as initially feared. We analyzed the levels of symptom expression and rates of Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), and COVID-19 related Posttraumatic Stress Disorder (C19-PTSD) in the adult population of Ireland at different points during the first year of the pandemic.Methods: Data were collected from a nationally representative sample of 1041 adults across five waves from March/April 2020 to March/April 2021. New participants were recruited at follow-up waves to maintain nationally representative cross-sectional estimates. Cross-sectional estimates of each and any disorder were calculated, and longitudinal changes in means and prevalence estimates of MDD, GAD, and C19-PTSD were assessed using structural equation modelling.Results: Cross-sectional estimates of meeting criteria for MDD, GAD, or C19-PTSD were 34.7% in March/April 2020 (Wave 1) and 33.7% in March/April 2021 (Wave 5). Longitudinal analyses revealed no significant change in symptoms of MDD, a significant decrease in GAD symptoms, and a significant increase in C19-PTSD symptoms. There were significant decreases in prevalence estimates of MDD (by 4.9%) and GAD (by 6.3%), and no significant change in C19-PTSD. Overall, 4.7% fewer people met criteria for any disorder at Wave 5 than at Wave 1. Conclusion: There was no evidence of an increase in mental health problems in the adult population during the first year of the pandemic in Ireland. Analyses of longitudinal data indicated a small but significant decrease in the proportion of people suffering from a mental health disorder.

Kanne and Bishop’s (2020) Editorial Perspective ‘The Autism waitlist crisis and remembering what families need’ offers a strong argument to provide greater access to high-quality assessments for Autism Spectrum Disorder (ASD). They note, correctly, that due to increasing numbers of referrals practitioners are under increasing pressure to provide quicker or abbreviated evaluations, that some cases are extremely complex and require considerable expertise to assess, and that a good assessment is a good investment in effective intervention. I agree with these points but also want to highlight some difficulties and dilemmas associated with the assessment of ASD; and to argue that improving access to assessments and interventions through the use of non-specialists and new technologies may be a promising direction.

Background Despite numerous efforts to improve maternal and child health in Malawi, maternal and newborn mortality rates remain very high, with the country having one of the highest maternal mortality ratios globally. The aim of this study was to identify which individual factors best predict utilisation of skilled maternal healthcare in a sample of women residing in Lilongwe district of Malawi. Identifying which of these factors play a significant role in determining utilisation of skilled maternal healthcare is required to inform policies and programming in the interest of achieving increased utilisation of skilled maternal healthcare in Malawi. Methods This study used secondary data from the Woman’s Questionnaire of the 2010 Malawi Demographic and Health Survey (MDHS). Data was analysed from 1126 women aged between 15 and 49 living in Lilongwe. Multivariate logistic regression was conducted to determine significant predictors of maternal healthcare utilisation. Results Women’s residence (P = .006), education (P = .004), and wealth (P = .018) were significant predictors of utilisation of maternal healthcare provided by a skilled attendant. Urban women were less likely (odds ratio [OR] = 0.47, P = .006, 95% CI = 0.28–0.81) to utilise a continuum of maternal healthcare from a skilled health attendant compared to rural women. Similarly, women with less education (OR = 0.32, P = .001, 95% CI = 0.16–0.64), and poor women (OR = 0.50, P = .04, 95% CI = 0.26–0.97) were less likely to use a continuum of maternal healthcare from a skilled health attendant. Conclusion Policies and programmes should aim to increase utilisation of skilled maternal healthcare for women with less education and low-income status. Specifically, emphasis should be placed on promoting education and economic empowerment initiatives, and creating awareness about use of maternal healthcare services among girls, women and their respective communities.

The Irish Mental Health Act (2001) is undergoing revision. In 2014 an Expert Review Group recommended that the term currently used in the act “mental disorder”, should be replaced with the term “mental illness”. We argue that the proposed change, while well intentioned, contradicts the internationally adopted terminology of “mental disorder” used by the United Nations, World Health Organisation and European Commission. The term “mental illness” is atavistic, it implies an unsupported cause, it contravenes the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), and it is associated with concerns regarding stigma and reduced self-efficacy. Furthermore, the term “mental illness” is not used in any internationally accepted diagnostic or classification system in the mental health field. While any term used to describe mental health problems, may be contested, Ireland should not revert to using archaic terminology. In accordance with international best practice, and perhaps in lieu of a willingness to accept more progressive alternatives, Ireland should continue to use cause-neutral terminology, such as “mental disorder”, in the revised Mental Health Act.

Contains fulltext : 245477.pdf (Publisher’s version ) (Open Access) BACKGROUND: Whilst assistive technology (AT) can play an important role to improve quality of life, health inequity regarding access to appropriate AT for people with intellectual disabilities (ID) is still very much present especially in low resource countries. OBJECTIVES: This study focused on exploring factors that influence access to and continued use of AT by people with ID in the Western Cape province of South Africa and to suggest potential implications of these findings and actions required to promote access to AT. METHOD: A qualitative approach was used to explore the experiences of people with ID and providers of AT. Face-to-face interviews with 20 adults with mild to profound ID, and 17 providers of AT were conducted and the data were analysed thematically. RESULTS: People with ID within the study setting faced many challenges when trying to access AT and for those who managed to acquire AT, its continued usage was influenced by both personal characteristics of the user and environmental factors. Important factors that influence AT access and use for people with ID found in this study were (1) attitudes from the community, (2) knowledge and awareness to identify AT need and (3) AT training and instructions to support the user and care network. CONCLUSION: With the perspectives of both the providers and users of AT, this study identified priority factors, which could be addressed to improve AT access and use for people with ID in the Western Cape province.

Background Equity and inclusion are important principles in policy development and implementation. The aim of this study is to explore the extent to which equity and inclusion were considered in the development of Malawi’s National Disability Mainstreaming Strategy and Implementation Plan. Methods We applied an analytical methodology to review the Malawi’s National Disability Mainstreaming Strategy and Implementation Plan using the EquIPP (Equity and Inclusion in Policy Processes) tool. The EquIPP tool assesses 17 Key Actions to explore the extent of equity and inclusion. Results The development of the Malawi National Disability Mainstreaming Strategy and Implementation Plan was informed by a desire to promote the rights, opportunities and wellbeing of persons with disability in Malawi. The majority (58%) of the Key Actions received a rating of three, indicating evidence of clear, but incomplete or only partial engagement of persons with disabilities in the policy process. Three (18%) of the Key Actions received a rating of four indicating that all reasonable steps to engage in the policy development process were observed. Four (23%) of the Key Actions received a score five indicating a reference to Key Action in the core documents in the policy development process. Conclusions The development of disability policies and associated implementation strategies requires equitable and inclusive processes that consider input from all stakeholders especially those whose wellbeing depend on such policies. It is pivotal for government and organisations in the process of policy or strategy development and implementation, to involve stakeholders in a virtuous process of co-production – co-implementation – co-evaluation, which may strengthen both the sense of inclusion and the effectiveness of the policy life-cycle.

IntroductionAssistive technology (AT) is important for the achievement of the sustainable development goals (SDGs) for persons with disabilities (PWD). Increasingly, studies suggest a significant gap between the need for and demand for and provisions of AT for PWD in low-income and middle-income settings. Evidence from high income countries highlights the importance of robust AT policies to the achievement of the recommendations of the World Health Assembly on AT. In Malawi, there is no standalone AT policy. The objectives of the Assistive Product List Implementation Creating Enablement of inclusive SDGs (APPLICABLE) project, are to propose and facilitate the development of a framework for creating effective national AT policy and specify a system capable of implementing such policies in low-income countries such as Malawi.Method and analysisWe propose an action research process with stakeholders in AT in Malawi. APPLICABLE will adopt an action research paradigm, through developing a shared research agenda with stakeholders and including users of AT. This involves the formation of an Action Research Group that will specify the priorities for practice—and policy-based evidence, in order to facilitate the development of contextually realistic and achievable policy aspirations on AT in Malawi and provide system strengthening recommendations that will ensure that the policy is implementable for their realisation. We will undertake an evaluation of this policy by measuring supply and support for specific AT prior to, and following the implementation of the policy recommendations.Ethics and disseminationThe study protocol was approved by Maynooth University Research Ethics Committee (SRESC-2019-2378566) and University of Malawi Research Ethics Committee (P.01/20/10). Findings from the study will be disseminated by publication in peer-reviewed journals, presentations to stakeholders in Malawi, Ireland and international audiences at international conferences.

There is a global need to provide human resources for health in low- and middle-income countries. To increase access to care, task shifting has been implemented in community-based rehabilitation (CBR) programs where skills and responsibilities are transferred to local people with shorter and more focused training. Through realist review and synthesis, this research aimed to consolidate the literature when considering (a) what skills CBR workers are reportedly using and/or being trained in relating to mental health, (b) how different settings affect how these task shifting programs work, and (c) the evidence of effectiveness when community health workers come from within the community itself. A total of 11 databases (PubMed, ABI/Inform Global, CINAHL, Cochrane, Emerald, Google Scholar, PsycINFO, SAGE, Science Direct, Scopus, and Web of Science) were systematically searched for specific terms relating to mental health, CBR, and low- and middle-income country. A total of 27 publications were identified as fitting the criteria (4 qualitative, 20 quantitative including 10 randomized controlled trials, and 3 noninvestigatory editorials). Core skills have been identified along with themes that affect how programs work in particular contexts. The use of task shifting in this area may be a potentially viable option for increasing access to mental health care. This resulted in the development of a theory to explain the outcomes being observed. When Task-shifting mental health intervention skills collaboration, harnessing resources available within the community, and the provision of ongoing supervision interact to influence awareness gains, social bonding, the building of trust, and the development of skills and understanding within the community itself. This effects intervention buy-in, overall effectiveness and sustainability, mental health symptoms and local empowerment. These findings can be considered when developing training programs for CBR mental health workers, as well as policy and intervention program design.

Background The World Health Organisation has launched a programme to promote Global Cooperation on Assistive Technology. Its aim is to increase access to high-quality affordable assistive products (AP) for everybody in need. People with intellectual disabilities (ID) are a specific group that could benefit from AP, but use less AP compared to their non-intellectual disabled peers. Method A systematic literature search was carried out to identify barriers and potential facilitators for access to AP for people with ID globally. The search strategy terms were ‘Intellectual Disability’ and ‘Assistive Technology’ with the following electronic literature databases PubMed, Embase, ASSIA, Web of Science, Medline, CINAHL complete, PsycInfo, Scopus and ERIC. The quality and relevance of the studies were assessed. Factors associated with access were identified thematically, categorised into barriers and facilitators and mapped into themes. Results In all, 22 key studies were retrieved, describing 77 barriers and 56 facilitators. The most frequently reported barriers were related to lack of funding and cost of AP, lack of awareness about AP and inadequate assessment. An increase of knowledge and awareness about AP and the need of AP for people with ID were most often extracted as factors that could potentially facilitate access. Conclusions This review proposes actions linked to the barriers and facilitators that have a particular importance for people with ID to access AP. Yet, only limited research is available describing factors that influence access to AP for people with ID in low and middle income countries and rural areas.

Background : In this study, we compared the prevalence of posttraumatic stress disorder (PTSD), depression, and generalized anxiety disorder (GAD) before and during the COVID-19 pandemic across nationally representative samples of Irish adults. Methods : Participants were sampled in February 2019 (N = 1,020), April 2020 (N = 1,041), May 2020 (N = 1,032), and December 2020 (N = 1,100) using the same self-report measures. Results : The prevalence of PTSD significantly increased from 12.5% in 2019 to 18.0% in April 2020, to 22.0% in May, and returning to 17.6% in December 2020. PTSD increases were most consistently observed in males, those aged 18–34 years, those without a university qualification, and those living in the Leinster region of Ireland, where the capital city of Dublin is located. There were no significant changes in the prevalence of depression or GAD. Limitations : The 2020 samples were not completely independent of one another and while the analysis took this into account, this bias cannot be completely removed. Conclusions : These findings show an increase in PTSD during the initial stages of the COVID-19 pandemic compared to the pre-pandemic period and suggest specificity in mental health responses to the COVID-19 pandemic.

PURPOSE/OBJECTIVE This article reviewed foundational principles in rehabilitation psychology and explored their application to global health imperatives as outlined in the World Report on Disability (World Health Organization & World Bank, 2011). RESEARCH METHOD/DESIGN Historical theories and perspectives are used to assist with conceptual formulation as applied to emerging international rehabilitation psychology topics. RESULTS According to the World Report on Disability (World Health Organization & World Bank, 2011), there are approximately 1 billion individuals living with some form of disability globally. An estimated 80% of persons with disabilities live in low- to middle-income countries (WHO, 2006). The primary messages and recommendations of the World Report on Disability have been previously summarized as it relates to potential opportunities for contribution within the field of rehabilitation psychology (MacLachlan & Mannan, 2014). Yet, undeniable barriers remain to realizing the full potential for contributions in low- to middle-income country settings. CONCLUSIONS/IMPLICATIONS A vision for engaging in international capacity building and public health efforts is needed within the field of rehabilitation psychology. Foundational rehabilitation psychology principles have application to the service of individuals with disabilities in areas of the world facing complex socioeconomic and sociopolitical challenges. Foundational principles of person-environment interaction, importance of social context, and need for involvement of persons with disabilities can provide guidance to the field as it relates to global health and rehabilitation efforts. The authors illustrate the application of rehabilitation psychology foundational principles through case examples and description of ongoing work, and link foundational principles to discreet domains of intervention going forward.

Purpose: Health should be a universal phenomenon. However, little is known about the relationship between disability status and health issues – particularly in rural areas. This study looks at health issues of persons with disabilities in Madwaleni, a rural impoverished area in South Africa in 2011, and compares them to persons with no disabilities. Materials and Methods: Standardized questionnaires were used in the survey to assess disability and health status. The sample comprised of 773 individuals – 322 persons with disability and 451 comparisons (without disability) – covering 527 households. Children under the age of five were excluded from the sample. We used purposive sampling. Results and Conclusion: This study found that persons with disabilities have poorer reported health outcomes than persons with no disabilities. There is also an association between disability severity and mental health issues as assessed by the GHQ-12. A significantly higher percentage of persons with disability did not get health care when needed. Persons with disabilities also have less favorable attitudes toward competence of health care workers. This study has shown greater health needs and less satisfaction with services, which strongly indicates insufficient access for persons with disabilities in a rural impoverished are within South Africa. •Implications for rehabilitation •Persons with disabilities in rural South Africa have poorer reported health outcomes. •Persons with disabilities have less favorable attitudes towards competence of health care workers in rural South Africa. •Better access to health care for persons with disabilities is needed in rural South Africa. The perceived needs-access gap for health services among persons with disabilities in a rural area within South Africa

Many people with intellectual disability (ID) are no longer isolated in “special care” facilities. Some settings such as the Scandinavian countries, North America and the UK have long experience in community living for people with ID. Others, such as Ireland, are currently moving people into community living [1,2]. Research has shown that deinstitutionalization (relocation of individuals with ID from institutional to community settings) can enhance their inclusion and wellbeing (8–10). A review of the literature on deinstitutionalization of care and support, covering research from 1997 to 2007, found that community living enhances interpersonal relationships, access to community services and self-determination, compared to living in large institutions [1]. The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) [3], a culmination of the normalization drive, enshrines community living for people with ID; people with all types of disabilities must enjoy all human rights and fundamental freedoms; all people with disabilities, should be part of the normal societal processes such as education, employment, housing, socialization and access to all societal services. In particular Article 19 of UNCRPD highlights the right to community living by all people with disabilities, a right to choose where and with whom to live, and a right to support to ensure social inclusion [2]. The Sustainable Development Goals (SDGs) [4], which reinvigorates the Millennium Development Goals [5], aims to “leave no one” behind through inclusion of all people, including those with ID who are among the most vulnerable to social exclusion [6]. It follows that then that people should not be “left behind”, either through exclusion in institutions, or through isolation in the community.

We welcome Jesus et al.’s paper, which makes an important contribution to the under-researched area of the physical rehabilitation workforce. The authors present recommendations to “advance a policy and research agenda for ensuring that an adequate rehabilitation workforce can meet the current and future rehabilitation health needs” (p. 1). We argue that their perspective could however be strengthened by adopting a stronger global perspective, including consideration of the needs of low-resource settings. In particular, we highlight the integral role of more effective sector and inter-sectoral governance, the opportunity to support the development of community-based rehabilitation (CBR), the lessons that can be learnt from human resources for health (HRH) research and practice more generally, and the recent developments in the global provision of assistive technologies. Each of these issues has important implications and contributions to make to advance the policy and research agenda for the global rehabilitation workforce.

Background It is estimated that over one billion persons worldwide have some form of disability. However, there is lack of knowledge and prioritisation of how to serve the needs and provide opportunities for people with disabilities. The community-based rehabilitation (CBR) guidelines, with sufficient and sustained support, can assist in providing access to rehabilitation services, especially in less resourced settings with low resources for rehabilitation. In line with strengthening the implementation of the health-related CBR guidelines, this study aimed to determine what workforce characteristics at the community level enable quality rehabilitation services, with a focus primarily on less resourced settings. Methodology This was a two-phase review study using (1) a relevant literature review informed by realist synthesis methodology and (2) Delphi survey of the opinions of relevant stakeholders regarding the findings of the review. It focused on individuals (health professionals, lay health workers, community rehabilitation workers) providing services for persons with disabilities in less resourced settings. Results Thirty-three articles were included in this review. Three Delphi iterations with 19 participants were completed. Taken together, these produced 33 recommendations for developing health-related rehabilitation services. Several general principles for configuring the community rehabilitation workforce emerged: community-based initiatives can allow services to reach more vulnerable populations; the need for supportive and structured supervision at the facility level; core skills likely include case management, social protection, monitoring and record keeping, counselling skills and mechanisms for referral; community ownership; training in CBR matrix and advocacy; a tiered/teamwork system of service delivery; and training should take a rights-based approach, include practical components, and involve persons with disabilities in the delivery and planning. Conclusion This research can contribute to implementing the WHO guidelines on the interaction between the health sector and CBR, particularly in the context of the Framework for Action for Strengthening Health Systems, in which human resources is one of six components. Realist syntheses can provide policy makers with detailed and practical information regarding complex health interventions, which may be valuable when planning and implementing programmes. © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/)

Disability is not a 'health problem'; however some people with disabilities do have increased health needs, and all people with disabilities have the same right to access health services as others. The number of people living with disabilities is increasing, due partly to increasing numbers of people living with the consequences of chronic communicable and non-communicable diseases. Based on recommendations of the World Report on Disability, which provides the parameters for research, this paper sets out a research agenda calling for a considerable research programme on social, civil, and economic impacts of living with disability, arising from whatever cause, including communicable and non-communicable diseases; significant global health policy revisions; identification of constraints and facilitators in access to healthcare for people with disabilities; development of a robust evidence base for implementing the new guidelines on community-based rehabilitation; innovations in addressing human resource challenges faced by disability and rehabilitation service-providers; development of enabling technologies that focus on individuals' aspirations and social gain; preparedness for responding to the needs of people with disabilities in disaster situations; and the application of disability metrics to strengthen health systems.

The World Health Organization has launched a program to promote Global Cooperation on Assistive Technology (GATE). The objective of the GATE program is to improve access to high quality, affordable assistive technology for people with varying disabilities, diseases, and age-related conditions. As a first step, GATE has developed the assistive products list, a list of priority assistive products based on addressing the greatest need at population level. A specific group of people who can benefit from user appropriate assistive technology are people with intellectual disabilities. However, the use of assistive products by people with intellectual disabilities is a neglected area of research and practice, and offers considerable opportunities for the advancement of population health and the realization of basic human rights. It is unknown how many people with intellectual disabilities globally have access to appropriate assistive products and which factors influence their access. We call for a much greater focus on people with intellectual disabilities within the GATE program. We present a framework for understanding the complex interaction between intellectual disability, health and wellbeing, and assistive technology.

Purpose statement: The article explores assistive technology sources, services and outcomes in South Africa, Namibia, Malawi and Sudan. Methods: A survey was done in purposively selected sites of the study countries. Cluster sampling followed by random sampling served to identify 400–500 households (HHs) with members with disabilities per country. A HH questionnaire and individual questionnaire was completed. Country level analysis was limited to descriptive statistics. Results: Walking mobility aids was most commonly bought/provided (46.3%), followed by visual aids (42.6%). The most common sources for assistive technology were government health services (37.8%), “other” (29.8%), and private health services (22.9%). Out of the participants, 59.3% received full information in how to use the device. Maintenance was mostly done by users and their families (37.3%). Devices helped a lot in 73.3% of cases and improved quality of life for 67.9% of participants, while 39.1% experienced functional difficulties despite the devices. Conclusion: Although there is variation between the study settings, the main impression is that of fragmented or absent systems of provision of assistive technology. * Implications for rehabilitation * Provision of assistive technology and services varied between countries, but the overall impression was of poor provision and fragmented services. * The limited provision of assistive technology for personal care and handling products is of concern as many of these devices requires little training and ongoing support while they can make big functional differences. * Rural respondents experienced more difficulties when using the device and received less information on use and maintenance of the device than their urban counterparts. * A lack of government responsibility for assistive device services correlated with a lack of information and/or training of participants and maintenance of devices.

The aim of this review is to evaluate the health and social effects of accessible home environments for people with functional limitations, in order to provide evidence to promote well-informed decision making for policy guideline development and choices about public health interventions. MEDLINE and nine other electronic databases were searched between December 2014 and January 2015, for articles published since 2004. All study types were included in this review. Two reviewers independently screened 12,544 record titles or titles and abstracts based on our pre-defined eligibility criteria. We identified 94 articles as potentially eligible; and assessed their full text. Included studies were critically appraised using the Mixed Method Appraisal Tool, version 2011. Fourteen studies were included in the review. We did not identify any meta-analysis or systematic review directly relevant to the question for this systematic review. A narrative approach was used to synthesise the findings of the included studies due to methodological and statistical heterogeneity. Results suggest that certain interventions to enhance the accessibility of homes can have positive health and social effects. Home environments that lack accessibility modifications appropriate to the needs of their users are likely to result in people with physical impairments becoming disabled at home.

Summary Points N As for any type of health care, decisions about interventions in the context of natural disasters, conflict, and other major healthcare emergencies must be guided by the best possible evidence. N Disaster health interventions and decision making can benefit from an evidence-based approach. N We outline how systematic reviews and methodologically sound research can build a much-needed evidence base. N We do this from the standpoint of Evidence Aid, an initiative that aims to improve access to evidence on the effects of interventions, actions, and policies before, during, and after disasters and other humanitarian emergencies, so as to improve health-related outcomes/

The BMJ ’s issue highlighting clinical and research malpractice is welcome,1 as is the recognition of trenchant resistance to change. Privileged groups seek to defend the indefensible.2 There is much privilege and profit to defend in health, including for health professional associations, corporations, and universities. Once qualified, clinical professionals find …

Purpose: Social inclusion of children with physical disabilities is essential for their mental health. The long-standing conflict and political instability in Palestine since 1948 has resulted in an unprecedented number of children with disabilities. This study aimed to assess social inclusion and mental health of children with physical disabilities in Palestine. Method: A mixed methods research design was used. The 12-item General Health Questionnaire and a Social Inclusion Questionnaire were administered to 100 children with amputations, 12-18 years of age, in the Gaza Strip. Ten semi-structured interviews were also conducted with personnel working across civil society rehabilitation services in the area, particularly in services that focussed on the physical rehabilitation of children who had lost a limb. Results: Quantitative findings indicated that 88% of children’s disabilities were caused by war-related incidents. While the sample of children showed on average relatively low levels of psychological distress, males reported feeling more socially included and having better mental health than did females. Furthermore, there was a strong positive correlation between mental health and social inclusion, and a moderate positive correlation between psychological distress and social inclusion. The qualitative data identified different factors that hinder social inclusion, mainly: political instability; under-resourced disability organisations; lack of coordinated efforts; and negative societal attitudes towards disability. Conclusion: A new questionnaire for social inclusion was developed, which can now be used as a tool to assess social inclusion in similar contexts; as well as a culturally-adapted form of the General Health Questionnaire-12 to assess mental health. There is a clear need for service-providers to move beyond a medical model of care to one that embraces community-based rehabilitation and the realisation of rights, in order to promote the social inclusion and mental health of children with disabilities in Palestinian society.

In recent decades, there has been a push to incorporate the World Health Organization “Health for All” principles in national, regional, and local health policy documents. However, there is still no methodology guiding the appraisal of such policies with regard to the extent that they address social inclusion. In this article, the authors report on the development of EquiFrame, a novel policy analysis framework that was used to evaluate the disability and rehabilitation policies of Malawi, Namibia, Sudan, and South Africa. The policies were assessed in terms of their commitment to 21 predefined core concepts of human rights and inclusion of 12 vulnerable groups. Substantial variability was identified in the degree to which the core concepts and vulnerable groups were featured in these policy documents. The overall summary rankings for the disability policies of the countries studied were as follows: Namibia–High, Malawi–Low, and Sudan–Low. The rehabilitation policy of South Africa was ranked as Low. The results support the idea that adequate disability and rehabilitation policies remain mostly undefined. EquiFrame may offer a useful methodology for evaluating and comparing human rights and social inclusion across policy documents.

People often feel unhappy in the morning but better later in the day, and this pattern may be amplified in the distressed. Past work suggests that one function of cortisol is to energize people in the mornings. In a study of 174 students we tested to see if daily affect patterns, psychological distress, and awakening cortisol levels were interlinked. Affect levels were assessed using the Day Reconstruction Method (Kahneman, Krueger, Schkade, Schwarz, & Stone, 2004) and psychological distress was measured using the Depression Anxiety Stress Scales (Antony, Bieling, Cox, Enns, & Swinson, 1998). On average positive affect increased markedly in a linear pattern across the day whilst negative affect decreased linearly. For the highly distressed this pattern was stronger for positive affect. Lower than average morning cortisol, as assessed by two saliva samples at waking and two samples 30 minutes after waking, predicted a clear increasing pattern of positive affect throughout the day. When we examined the interlinkages between affect patterns, distress, and cortisol our results showed that a pronounced linear increase in positive affect from morning through to evening occurred chiefly among distressed people with below average cortisol levels upon awakening. Psychological distress, whilst not strongly associated with morning cortisol levels, does appear to interact with cortisol levels to profoundly influence affect.

IntroductionThe aim of this review is to answer the following question:Does assistive technology contribute to social inclusion for people with intellectual disability?Previous research on assistive technology has focused on socioeconomic impacts such as education, employment and access to healthcare by people with intellectual disability. There is a need to consolidate evidence on the interaction between intellectual disability, assistive technology, community living and social inclusion.Methods and analysisThe review will consider studies from all settings: geographical, socioeconomic and care (institutional and community care), published in English. Studies reported in other languages with abstracts in English will be included if they can be translated using Google Translate, otherwise such studies will be included in the appendix. The review will include both qualitative and quantitative studies. The intervention in this review refers to the use of assistive technology to promote community participation or interpersonal relationships (social inclusion) for people with intellectual disability. The outcomes will be behavioural and social benefits of using assistive technology by people with intellectual disability. Enhanced interpersonal relationships and community participation by people with intellectual disability. Data analysis will be in two phases. The first phase will involve analysis of individual study designs separately. The second phase will be narrative/thematic synthesis of all study groups.EthicsThe review will not create any ethical or safety concerns.DisseminationAt least one peer-reviewed article in a leading journal such as theBMJis planned. The findings will also be disseminated through a seminar session involving internal audience at Trinity College Dublin and within the Assistive Technologies for people with Intellectual Disability and Autism research programme.PROSPERO registration numberCRD42017065447; Pre-results.

Aim To examine psychosocial adjustment in persons with lower limb amputations related to diabetes. Methods Thirty-eight participants with diabetes-related lower limb amputations, recruited from two limb-fitting centres, completed three psychological self-report assessments: the Trinity Amputation and Prosthesis Experience Scales (TAPES); the Hospital Anxiety and Depression Scale (HADS); and the Amputation Body Image Scale—Revised (ABIS-R). Results Over 18% of participants scored above the normal range (> 8) for depression on the HADS and 18.5% scored above the normal range for anxiety. Both depression (ρ = 0.75, P

Background : There is international evidence that people with disabilities face barriers when accessing primary healthcare services and that there is inadequate information about effective interventions that work to improve the lives of people with disabilities, especially in low-income and middle-income countries. Poor rural residents generally experience barriers to accessing primary healthcare, and these problems are further exacerbated for people with disabilities. Objective : In this study, we explore the challenges faced by people with disabilities in accessing healthcare in Madwaleni, a poor rural Xhosa community in South Africa. Design : Purposive sampling was done with 26 participants, using semi-structured interviews and content analysis to identify major themes. Results : This study showed a number of barriers to healthcare for people with disabilities. These included practical barriers, including geographical and staffing issues, and attitudinal barriers. Conclusions : It is suggested that although there are practical barriers that need to be addressed, attitudinal barriers could potentially be addressed more easily and cost effectively. Keywords : disability; rural; access; health; barriers (Published: 1 October 2015) Citation: Glob Health Action 2015, 8 : 29003 - http://dx.doi.org/10.3402/gha.v8.29003

This study examines the contribution of demographic/amputation-related variables and coping strategies to the prediction of psychosocial adaptation in veterans with acquired lower limb amputations. Multiple indicators of the psychosocial adjustment of 796 individuals in the UK aged between 26–92 years with lower limb amputations were assessed. Hierarchical linear regressions were performed to investigate relationships between demographic/amputationrelated variables (i.e. age, time since amputation, amputation level and amputation aetiology), the dimensions of coping (namely problem solving, seeking social support and avoidance) and self-reported adaptation to amputation, as well as symptoms of intrusion, anxiety and depression. Results indicated that coping styles were important predictors of psychosocial adaptation. Avoidance was strongly associated with psychological distress and poor adjustment. In contrast, problem solving was negatively associated with depressive and anxious symptomatology whereas seeking social support was negatively associated with symptoms of depression and positively associated with social adaptation. These findings suggest the potential for interventions designed to promote particular coping strategies to improve psychosocial outcomes.

Desmond DM, MacLachlan M: Factor structure of the Trinity Amputation and Prosthesis Experience Scales (TAPES) with individuals with acquired upper limb amputations. Am J Phys Med Rehabil 2005;84:506-513. Objectives: To investigate the factorial composition of the Trinity Amputation and Prosthesis Experience Scales (TAPES), a multidimensional assessment of adaptation to amputation and prosthesis, for use with individuals with acquired upper limb amputations. Design: Cross-sectional survey of members of the British Limbless Ex-Service Men's Association. Results: A total of 101 individuals (men, 100; mean age, 73.8 yrs, SD 11.94) with acquired upper limb amputations (98 traumatic cases) completed the TAPES. Principal components analyses with varimax rotation revealed four psychosocial subscales (general adjustment, social adjustment, optimal adjustment, and adjustment to limitation), four activity-restriction subscales (restriction of lifestyle, social restriction, occupational restriction, and restriction of mobility), and a single prosthesis-satisfaction subscale. Each of these subscales had high internal reliability. Conclusions: The TAPES structure can be meaningfully represented in terms of nine internally consistent subscales. Additional research needs to be done on the TAPES, for use with individuals with upper limb amputations. In particular studies of the scales, predictive validity is warranted.

Background There has been little attention to the underlying dimensional structure of the Hospital Anxiety and Depression Scale (HADS) in analyses involving individuals older than 65 years of age despite its routine application in this age group. Methods The factor structure of the HADS was investigated using a sample of 680 veterans with limb amputations who were aged at least 66 years (mean 79.0, SD 5.02; range 66–92) Four models were specified and estimated using Lisrel 8.54. Model 1 specified a uni-dimensional structure. Model 2 specified a correlated two-factor model. Model 3 specified a correlated two-factor model but with cross factor loadings for item 7. Model 4 specified a three-factor model after Clark and Watson's (1991) tripartite theory of anxiety and depression. Results Models 2, 3 and 4 were found to adequately fit the data. However, on balance, model 4 was found to be a better explanation of the data than the alternative specifications. Conclusions The results indicate that factor models for the HADS developed in younger samples are replicable with older adults, thus supporting the suggestion that the HADS structure is invariant for age. However, considering the composition of the current sample, i.e. veterans with limb amputations, further research is necessary to determine whether these findings are generalisable to the wider population of older adults. Copyright © 2005 John Wiley & Sons, Ltd.

We welcome Andrew Haig's critique of our paper, "Disability & Health: A research agenda" in Social Inclusion. Our paper sought to identify research priorities to better understand, provide enhanced services and a better quality of life for people with disabilities, particularly in relation to their health and wellbeing. Haig's critique makes several important points that deserve serious consideration. His comments reflect a view of the relationship between disability and health which is different from the one we have espoused. Specifically, Haig argues that (a) disability is a health problem, (b) medical rehabilitation should be separated from Community Based Rehabilitation (CBR), and (c) the evidence base for medical rehabilitation is much stronger than for CBR. We address each of these points below arguing that while some types of disability clearly result from health problems; often disability is not experienced as a health problem; and sometimes, disability in interaction with restricted access is the cause of health problems.

Objectives To undertake preliminary research into quality of life (QOL) for a group of people with a lower-limb amputation and to investigate what aspects of the "prosthetic experience" are most strongly associated with QOL using the Trinity Amputation and Prosthesis Experience Scales (TAPES). Design Cross-sectional survey. Setting Prosthetic limb fitting center. Participants Sixty-three people older than 18 years with unilateral lower-limb amputation. Interventions Not applicable. Main outcome measures The TAPES and the World Health Organization Quality of Life Questionnaire-Brief Version. Results There were no significant differences in any of the QOL domain scores (physical health, psychological, social relationships, environmental) arising from age, gender, level of amputation, or cause of amputation. However, there were significant differences depending on the length of time living with the prosthesis and the degree of prosthetic use. Stepwise regression identified different significant predictors for each domain of QOL. Conclusions These findings support the claim that the TAPES can be used to evaluate QOL for this patient group. Further research is warranted to learn how sensitive the scale and its items are to change in clinical status.

Camps offering therapeutic recreation-based programmes seek to provide a positive experience for children with life-threatening illnesses, and their siblings. While such programmes are undoubtedly motivated by the best of intentions, there are very little data available on children’s own experiences in them. This article addresses this by investigating children’s experiences in The Barretstown Gang Camp in Ireland. A questionnaire was completed by 449 children from 15 European countries. Feedback was factor analysed to construct an empirical model of how liking for activities in the programme clustered. Eight distinct components were identified.. Results indicated that children’s level of liking for some components and whether they felt their friends would like to come to camp were influenced by their age, gender, nationality, level of understanding of explanations in camp and patient/sibling status. Children’s descriptions of their camp experience emphasized themes pertaining to fun, activities, scenic surroundings, staff and multiculturalism.

The involvement of psychologists in medical settings has grown at a tremendous rate in recent years, with an ever-increasing number of medical environments developing and promoting interdisciplinary collaboration, and thus enabling psychologists to extend their practice beyond the traditional mental health model. In the context of prosthetic and orthotic practice, we suggest that the realization of the potential of technological innovations in this field may only fully be achieved by equipping prosthetists and orthotists not only with the technical expertise they require but also by fostering an awareness of the importance of psychosocial issues in amputation and rehabilitation, and an understanding of the psychological complexities pertaining to the therapeutic context. Rehabilitation after amputation is fundamentally dependent on the patient’s psychological adjustment to the injury; hence, practitioners’ sensitivity to psychosocial issues has clear practical implications both for successful prosthetic fitting and rehabilitation, and for continuing development and innovation in the discipline. This article highlights a number of key psychosocial issues of particular relevance to prosthetic and orthotic practice and of special importance to the rehabilitation of the amputee.

This African Journal of Disability supplement focuses on papers presented at the third AfriNEAD Symposium in 2011. In this closing editorial, we want to give an overview of the rationale and major modes of operation of the African Network for Evidence-to-Action on Disability (AfriNEAD) with special focus on recommendations made at the 2011 AfriNEAD Symposium. AfriNEAD is guided and informed by the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) for its research themes. The issues that emerged from AfriNEAD 2011 ranged from children and youth with disabilities; education across the lifespan; economic empowerment; the development process in Africa; health, HIV and AIDS and community-based rehabilitation; holistic wellness; to research evidence and utilisation. Disability-related stigma, the value of emancipatory research and the need to recognise a broader scope of valid methodologies were also highlighted.

Objective This study reviewed the World Report on Disability (World Health Organization & World Bank, 2011) and explored its implications for rehabilitation psychology. Method Key findings and recommendations were identified within the World Report and issues that are salient to the profession, practice and research within rehabilitation psychology were highlighted. Results The World Report has a particular emphasis on disability in low-income countries, where the majority of people with disabilities live. Despite the origins and development of rehabilitation psychology within high-income countries, the profession has much to contribute to addressing many of the challenges identified in the World Report. Specific targeted contributions might include addressing the human resources for health crisis in rehabilitation; developing prosocial and community-based interventions and programs; helping to identify and overcome difficulties to accessing health care; refining the measurement and classification of disability; and strengthening research, policy and advocacy for and with people with disabilities. Implications The World Report on Disability presents exciting and challenging opportunities that exist for rehabilitation psychology practitioners and researchers, and for the profession itself.

The ethos of technical assistance in emergency relief work has emphasised the importance of recruiting people with appropriate professional and technical skills to work under the difficult circumstances of disasters. The authors used the Critical Incident Technique to assess jobrelated skills that were seen to be crucial for the achievement of the objectives towards which emergency relief personnel were working. Fifteen Irish nurses, working predominantly in refugee camps, identified over 60 different work objectives and 54 distinct job-related skills. It is argued that greater account should be taken of the variety of objectives which motivates such fieldworkers. The job-related skills identified were primarily process- rather than outcome-oriented skills, and the authors hold that a greater emphasis should be placed on the development of fluid as opposed to crystallised skills. The possibilities of using the Critical Incident Technique as a mechanism for feeding back authentic field experience and opera...

Objective: To develop a multidimensional self-report instrument to better understand the experience of amputation and adjustment to a lower limb prosthesis. Design: One hundred four participants completed a mail questionnaire consisting of 3 sections: psychosocial issues, activity restriction, and satisfaction with a prosthesis. Results: Factor analysis revealed 3 psychosocial subscales (General Adjustment, Social Adjustment, and Adjustment to Limitation), 3 activity restriction subscales (Functional Restriction, Social Restriction, and Athletic Activity Restriction), and 3 satisfaction subscales (Functional Satisfaction, Aesthetic Satisfaction, and Weight Satisfaction). The subscales displayed high internal reliability, and preliminary evidence indicated various forms of validity. Conclusion: These findings suggest that the Trinity Amputation and Prosthesis Experience Scales may be applied as a clinical and research tool.

The psychosocial problems and mediators of mental health were investigated in an adult sample of 74 Malawian returnees. A semi-structured interview indicated a number of specific problems facing the returnees, including reclaiming land, discrimination and disappointed expectations. A demographic questionnaire, the Coping Strategy Indicator, the Harvard Trauma Questionnaire, and the Generalised Self-Efficacy Scale were used to identify potential mediating factors on mental health as measured by the Self Reporting Questionnaire and number of visits to a doctor/healer in the last year. Stepwise Regression analysis revealed that number of trauma events experienced, generalised self-efficacy and gender were significant predictors of mental health. However, there was no significant relationship between the measures of coping strategies and mental health. These results are discussed in relation to theories of stress, learned helplessness, and the possibility of facilitating returnee reintegration. The importance of contextualising the aims and instruments of research is emphasised.

Kornor et al. (1) reviewed the results of studies comparing early trauma-focused cognitive-behavioural therapy (TFCBT) with supportive counselling (SC) in people identified as being at risk of developing traumatic stress related symptoms. They suggest that their results provide some evidence for the relative benefit of TFCBT in preventing chronic post-traumatic stress disorder (PTSD), and related symptoms. We question the extent to which this conclusion applies to the subgroup of people who have experienced traumatic physical injuries. Our systematic review of the efficacy of psychosocial interventions for preventing the onset of disability in people who had experienced traumatic physical injuries emphasizes the equivocal nature of current research, notes some negative outcomes and cautions for very careful monitoring of such interventions should they be used. There is a need for further high quality research exploring the optimal timing and nature of such interventions, as well as who is most likely to benefit from them. Kornor et al. (1) sought to evaluate the effectiveness of trauma-focused cognitive behaviour therapy (TFCBT) in preventing chronic Post-Traumatic Stress Disorder (PTSD), anxiety and depression. They included randomised controlled trials (RCTs) published in peer reviewed journals; people with diagnosed symptoms of Acute Stress Disorder (ASD) or symptoms of PTSD; those who had received TFCBT initiated within three months of the identified traumatic event; a non-pharmacological comparison intervention; and where outcomes were measured at follow- up of a minimum of one month after treatment. Seven papers from an initial search of 1438 studies met these criteria.

Health education programmes need to address local understandings of HIV/AIDS within the broader context of sexual behaviour. We report on a locally derived and community orientated questionnaire survey of HIV/AIDS and sexually related behaviour among 756 pupils from two government secondary schools in Malawi. On average, pupils gave the correct answers to more than 70% of the items on the survey. Seventy-two pupils from one of the schools subsequently participated in playing an educational board game about AIDS, once a week, over four weeks. The percentage of correct responses given while playing the board game significantly increased each time the board game was played, and a one-month follow-up questionnaire showed that a significant improvement had been maintained in comparison with the initial questionnaire survey. Pupils who attended the school where the board game was trialed, but Who did not participate in the board game, scored slightly, but significantly, higher than pupils from the other 'no-board game' control school. This result was tentatively interpreted as a 'trickle down' effect. The benefits of introducing active learning methods into schools, of focusing on local understandings of health problems, and of establishing an accurate knowledge base for health promotion are discussed.