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Background Assistive technology is central to the realization of the rights of persons with disabilities. However, there remains limited access to assistive technology throughout much of the world, with particularly poor access in lower- and middle-income countries. Evaluating stakeholder engagement in assistive technology networks has been used as a successful strategy to understand and address gaps in the assistive technology ecosystem. Objective The objective of this research was to provide an overview of the Kenyan Assistive Technology Ecosystem, including available assistive products and related services, and an understanding of the nature and strength of relationships between stakeholders Methods In this study, we employed an online qualitative stakeholder survey (2021) with representatives of organizations involved in assistive technology in Kenya. Results The assistive technology network in Kenya is distributed, with Government Ministries and Agencies and Organizations of persons with disabilities central to the network. The strength of relationships is concentrated on awareness and communication, with fewer organizations actively collaborating. Innovation training organizations are not yet well integrated into the network. Conclusions Improving access to assistive technology in Kenya will benefit from greater collaboration amongst all assistive technology stakeholders.

# Background Many people with disabilities in low-income settings, such as Sierra Leone, do not have access to the assistive technology (AT) they need, yet research to measure and address this issue remains limited. This paper presents a case study of the Assistive Technology 2030 (AT2030) funded Country Investment project in Sierra Leone. The research explored the nature and strength of the AT stakeholder network in Sierra Leone over the course of one year, presenting a snapshot of the network before and after a targeted systems level investment. # Methods Mixed-method surveys were distributed via the Qualtrics software twice, in December 2021 and September 2022 to n=20 and n=16 participants (respectively). Qualitative data was analyzed thematically, while quantitative data was analyzed with the NodeXL software and MS Excel to generate descriptive statistics, visualizations, and specific metrics related to indegree, betweenness and closeness centrality of organizations grouped by type. # Results Findings suggest the one-year intervention did stimulate change within the AT network in Sierra Leone, increasing the number of connections within the AT network and strengthening existing relationships within the network. Findings are also consistent with existing data suggesting cost is a key barrier to AT access for both organizations providing AT and people with disabilities to obtain AT. # Conclusion While this paper is the first to demonstrate that a targeted investment in AT systems and policies at the national level can have a resulting impact on the nature and strength of the AT, it only measures outcomes at one-year after investment. Further longitudinal impact evaluation would be desirable. Nonetheless, the results support the potential for systemic investments which leverage inter-organizational relationships and prioritize financial accessibility of AT, as one means of contributing towards increased access to AT for all, particularly in low-income settings.

Abstract Background Using digital technologies to provide services and supports remotely may improve efficiency and accessibility of healthcare, and support people with disabilities to live independently. This study aimed to explore the experience of using digital technologies to access and provide disability services and supports during the Covid-19 pandemic, from the perspective of people with disabilities, families and service providers. Methods Using a multiple case study design, we purposively sampled three cases based on service user characteristics and geographical reach of the service. We conducted semi-structured interviews with 40 service users and service providers. Topic guides and analysis were informed by the Consolidated Framework for Implementation Research (CFIR). Analysis followed a largely deductive approach, using the CFIR constructs as a coding framework. A summary memo was developed for each case. Influence and strength of each construct was rated to identify constructs that influenced implementation of digital technologies. Ratings were compared across services to identify facilitators and barriers to implementation. Results Service users and providers were positive about using digital technologies to access and provide disability services and supports remotely. Advantages over in-person delivery included reduced travel time, increased opportunity for peer support and peer learning, more choice and opportunity to participate in activities, and an enhanced sense of self while accessing services from the secure environment of their home. The urgency to identify new modes of service delivery to meet the needs of service users during Covid-19 was a strong facilitator but did not necessarily result in successful implementation. Other factors that were strong facilitators were the use of adaptations to enable service users to access the online service, service users’ willingness to try the online service, service users’ persistence when they encountered challenges, and the significant time and effort that service providers made to support service users to participate in the online service. Barriers to implementation included the complexity of accessing online platforms, poor design quality of online platforms, and organisations prioritising in-person delivery over online services. Conclusions These findings may allow service providers to leverage facilitators that support implementation of online disability services and supports.

Background The frequent prescribing of psychotropics and high prevalence of polypharmacy among older adults with intellectual disabilities require close monitoring. Aims To describe change in prevalence, predictors and health outcomes of psychotropic use during the four waves (2009/2010, 2013/2014, 2016/2017, 2019/2020) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA). Method Eligible participants were adults (≥40 years) with intellectual disabilities who participated in all four waves of IDS-TILDA and who reported medication use for the entire period. Differences between groups were tested using Cochran's Q test for binary variables and the McNemar–Bowker test for variables with more than two categories. Generalised estimating equation models were used to assess associations between psychotropic use, participants’ characteristics and health outcomes. Results Across waves (433 participants) there were no significant differences in prevalence of psychotropic use (61.2–64.2%) and psychotropic polypharmacy (42.7–38.3%). Antipsychotics were the most used subgroup, without significant change in prevalence between waves (47.6–44.6%). A significant decrease was observed for anxiolytics (26.8–17.6%; P < 0.001) and hypnotics/sedatives (14.1–9.0%; P < 0.05). A significant increase was recorded for antidepressants (28.6–35.8%; P < 0.001) and mood-stabilising agents (11.5–14.6%; P < 0.05). Psychotropic polypharmacy (≥2 psychotropics) was significantly associated with moderate to total dependence in performing activities of daily living over the 10-year period (OR = 1.80, 95% CI 1.21–2.69; P < 0.05). Conclusions The study indicates an increase in usage of some classes of psychotropic, a reduction in others and no change in the relatively high rate of antipsychotic use over 10 years in a cohort of older adults with intellectual disabilities and consequent risk of psychotropic polypharmacy and medication-related harm.

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) establishes that people with disabilities shall enjoy their human rights on an equal basis with others. Those rights include the right to legal capacity and to protection against discrimination, including intersectional and multiple forms of discrimination on the basis of disability and gender. In an effort to support the realisation of the CRPD, the United Nations team in Serbia undertook a project to address the implementation of these rights under the UN Partnership on the Rights of Persons with Disabilities (UNPRPD) programme. Namely, by bringing together stakeholders from the UN, government and civil society, the UNPRPD project in Serbia sought to create structural changes to uphold the rights of people with disabilities. With a view of understanding the process of change within, rather than the outcomes of, this UPRPD project, twenty-eight semi-structured interviews were conducted using the Most Significant Change Technique (MSCT) with key stakeholders involved in such a project. The interviews were analysed using Interpretive Phenomenological Analysis (IPA) to preserve the unique and diverse perspectives of participants who had differing roles across the project. The analysis allowed us to identify a number of facets of the process that facilitate structural change: coalition-building events; strengthening stakeholder capacity and relationships; the participation of persons with disabilities; and innovation in terms of what made the project significant, novel and in itself a change. All these facets are discussed in this article, with the purpose of supporting global efforts in alignment with the CRPD. On the whole, this article aims to support a better understanding of disability-inclusive development projects in line with the CRPD and to give evidence on how countries may begin to tackle the structural exclusion of persons with disabilities in society.

Understanding the complexity of informed consent processes is critically important to the success of research that requires participants to test, develop, or inform research data and results. This is particularly evident in research involving persons experiencing neurodegenerative diseases (e.g., Alzheimer’s disease, dementia) that impair cognitive functioning, who according to national law are considered to have a diminished capacity, or to lack the capacity, to consent to research participation. Those who would potentially benefit most from applied research participation may be excluded from participating and shaping data and outcomes. This article offers insights into challenges faced by the Smart and Healthy Ageing through People Engaging in Supportive Systems (SHAPES) Project in obtaining the consent of older persons, including older persons with disabilities. The promotion of continuing health, active ageing, and independent living is central to SHAPES, requiring project partners to reflect on traditional informed consent approaches to encourage the full, cognisant participation of older persons with disabilities. We examine how this issue may be addressed, with reference to the inclusive approach of SHAPES. In respecting the inalienable legal capacity of all legal persons, SHAPES uses the UN Convention on the Rights of Persons with Disabilities (CRPD) and the human rights model of disability as part of the theoretical framework. A novel, inclusive, representative informed consent framework was designed and is detailed herein. This framework provides significant opportunity to advance the inclusion of persons with disabilities or those experiencing neurodegenerative diseases in innovative research and is readily transferable to other research studies. The SHAPES approach is a substantial contribution to research on informed consent, demonstrating the utility of the human rights model of disability in facilitating the full research participation of target populations.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has impacted all segments of society, but it has posed particular challenges for the inclusion of persons with disabilities, those with chronic illness and older people regarding their participation in daily life. These groups often benefit from assistive technology (AT) and so it is important to understand how use of AT may be affected by or may help to mitigate the impacts of COVID-19. ObjectiveThe objectives of this study were to explore the how AT use and provision have been affected during the initial stages of the COVID-19 pandemic, and how AT policies and systems may be made more resilient based on lessons learned during this global crisis. MethodsThis study was a rapid, international online qualitative survey in the 6 United Nations (UN) languages (English, French, Spanish, Russian, Arabic, Mandarin Chinese) facilitated by extant World Health Organization (WHO) and International Disability Alliance networks. Themes and subthems of the qualitative responses were identified using Braun and Clarke’s 6-phase analysis. ResultsFour primary themes were identified in in the data: Disruption of Services, Insufficient Emergency Preparedness, Limitations in Existing Technology, and Inadequate Policies and Systems. Subthemes were identified within each theme, including subthemes related to developing resilience in AT systems, based on learning from the pandemic. ConclusionCOVID-19 has disrupted the delivery of AT services, primarily due to infection control measures resulting in lack of provider availability and diminished one-to-one services. This study identified a need for stronger user-centred development of funding policies and infrastructures that are more sustainable and resilient, best practices for remote service delivery, robust and accessible tools and systems, and increased capacity of clients, caregivers, and clinicians to respond to pandemic and other crisis situations.

While the technological revolution is accelerating, digital poverty is undermining the Sustainable Development Goals. This article introduces a justice-oriented digital framework which considers how fair access to digital capabilities, commodities, infrastructure, and governance can reduce global inequality and advance the SDGs.

Background Assistive technologies promote participation and quality of life for people with disabilities and other functional limitations. There is a global call to develop and implement policies to improve access to assistive technologies. In response, a stakeholder led initiative in Malawi is working towards the development of such a policy. Objective The objective of this study was to assess the existing network of stakeholders, and the strength of relationship between organizations who deliver assistive products and related services. Method We conducted a survey-based network analysis of assistive technology stakeholder organizations in Malawi. Results Stakeholders (n = 19) reported a range of connections, from no awareness to collaboration with organizations within the assistive technology network. No single organization or government ministry was most central to the network. International NGOs were less central to the network than local organizations for disabled people, service providers, and ministries. Conclusion The assistive technology stakeholder network in Malawi is distributed, with a range of responsibility across a variety of stakeholders, including three government ministries. An effective assistive technology policy must engage all stakeholders and may benefit from a collective leadership approach that spans the inter-sectoral need for a cohesive assistive technology system.

Abstract 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.

Background: Appropriate provision of assistive technology services (ATS) and products are a global health issue and essential for achieving the Sustainable Development Goals (SDGs). The Sixth African Network for Evidence-to-Action on Disability (AfriNEAD) conference included a workshop on collaboration, cohesion and coherence in ATS delivery in Africa. Objective: This article aimed to summarise the workshop proceedings and to provide some recommendations on how coherence and cohesion can be facilitated in assistive technology services in Africa. Method: A round table and small group discussions on assistive technology were facilitated in the virtual space of the AfriNEAD conference. Organisations and role players in ATS and products in Africa participated as keynote speakers, round table members and in small group discussions. Results: There was consensus amongst participants that cohesive collaboration must be facilitated. They further agreed that users must be central to future action. There are local, national and regional initiatives, but none of these have grown into an African assistive technology platform. World Health Organization (WHO) Africa can bring partners together and facilitate creation, officialisation and operationalising of a continental assistive technology platform, through building on the existing initiatives. The AfriNEAD disability research country working groups can act as in-country coordinating bodies for ATS and afford a possibility of a structured approach to assistive technology research. Conclusion: It is time to break away from Western institutionalised biomedical ways of providing ATS in Africa. Africans must develop coherent, cohesive ATS driven by empowered users who build on Africa’s strengths and addresses the continents’ unique needs.

The value of Assistive Technology in enabling active and equal participation in political, social, economic, and cultural life of people with disabilities, people ageing, and people with chronic conditions is broadly accepted. However, most of the global population who need assistive technology (AT) lack access to it, hence the call for international efforts to improve access to AT. Drawing from the capability approach (CA) developed by Amartya Sen and Martha C. Nussbaum, we explore factors that may hinder or facilitate access to AT. We examine the idea of an AT Passport as an innovative user-centered approach for improving access to AT. We used Interpretative Phenomenological Analysis (IPA) to explore service users’ lived experiences of access to AT and their understanding of the AT Passport concept. We identified the core values of human diversity, equity, access to opportunity, and individual freedom to choose a life of significance to them. Access to AT is central to expanding these capabilities subject to conducive personal and social-contextual issues. The AT Passport could be developed as a capability-enhancing resource by facilitating access to AT, harnessing the diversity of people’s personal, social, and environmental factors to enrich peoples’ capability sets. Further research is required to identify core AT Passport functionalities, usability, and acceptability features.

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.

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.

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.

Introduction Assistive 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 analysis We 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 dissemination The 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.

As people age, they are more likely to develop multiple chronic diseases and experience a decline in some of their physical and cognitive functions, leading to the decrease in their ability to live independently. Innovative technology-based interventions tailored to older adults’ functional levels and focused on healthy lifestyles are considered imperative. This work proposed a framework of active and healthy ageing through the integration of a broad spectrum of digital solutions into an open Pan-European technological platform in the context of the SHAPES project, an EU-funded innovation action. In conclusion, the SHAPES project can potentially engage older adults in a holistic technological ecosystem and, therefore, facilitate the maintenance of a high-quality standard of life.

Background Equity and social inclusion for vulnerable groups in policy development processes and resulting documents remain a challenge globally. Most often, the marginalization of vulnerable groups is overlooked in both the planning and practice of health service delivery. Such marginalization may occur because authorities deem the targeting of those who already have better access to healthcare a cheaper and easier way to achieve short-term health gains. The Government of Malawi wishes to achieve an equitable and inclusive HIV and AIDS Policy. The aim of this study is to assess the extent to which the Malawi Policy review process addressed regional and international health priorities of equity and social inclusion for vulnerable groups in the policy content and policy revision process. Methods This research design comprised two phases. First, the content of the Malawi HIV and AIDS Policy was assessed using EquiFrame regarding its coverage of 21 Core Concepts of human rights and inclusion of 12 Vulnerable Groups. Second, the engagement of vulnerable groups in the policy process was assessed using the EquIPP matrix. For the latter, 10 interviews were conducted with a purposive sample of representatives of public sector, civil society organizations and development partners who participated in the policy revision process. Data was also collected from documented information of the policy processes. Results Our analyses indicated that the Malawi HIV and AIDS Policy had a relatively high coverage of Core Concepts of human rights and Vulnerable Groups; although with some notable omissions. The analyses also found that reasonable steps were taken to engage and promote participation of vulnerable groups in the planning, development,implementation, monitoring and evaluation processes of the HIV and AIDS Policy, although again, with some notable exceptions. This is the first study to use both EquiFrame and EquIPP as complimentary tools to assess the content and process of policy. Conclusion While the findings indicate inclusive processes, commitment to Core Concepts of human rights and inclusion of Vulnerable Groups in relation to the Malawi HIV and AIDS Policy, the results also point to areas in which social inclusion and equity could be further strengthened.

Abstract 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.

Background The United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD) is a milestone in the recognition of the human rights of persons with disabilities, including the right to health and rehabilitation. South Africa has signed and ratified the CRPD but still has a long way to go in reforming policies and systems in order to be in compliance with the convention. This paper seeks to fill a gap in the literature by exploring what the barriers to the implementation of the health and rehabilitation articles of the CRPD are, as identified by representatives of the disability community. Methods This investigation used a qualitative, exploratory methodology. 10 semi-structured interviews of a purposive sample of representatives of disabled persons organizations (DPOs), non-governmental organizations (NGOs), and service providers in South Africa were conducted. Participants were drawn from urban, peri-urban, and rural settings in order to reflect diverse perspectives within South Africa. Data was analysed using a multi-stage coding process to establish the main categories and relationships between them. Results Six main categories of barriers to the implementation of the health and rehabilitation articles of the CRPD were identified. Attitude barriers including stigma and negative assumptions about persons with disabilities were seen as an underlying cause and influence on all of the other categories; which included political, financial, health systems, physical, and communication barriers. Conclusion The findings of this study have important implications for strategies and actions to implement the CRPD. Given the centrality of attitudinal barriers, greater sensitization around the area of disability is needed. Furthermore, disability should be better integrated and mainstreamed into more general initiatives to develop the health system and improve the lives of persons living in poverty in South Africa.

Background: Seafarers are amongst occupational groups with the highest risk for stress, a factor known to impact on mental health. Psychological issues such as depression, anxiety, suicide, and alcohol or drug dependence are recognized health problems within the maritime sector. The primary aim of this study was to identify which individual and occupational factors, known to impact on psychological functioning across the maritime industry and other sectors, best predict perceived stress and job satisfaction among a sample of merchant seafarers.Methods: Secondary data analysis was conducted using a work experiences and attitudes questionnaire administered by a large shipping company to seafarers within their organization. Structural equation modeling was conducted using a proposed theoretical model of perceived stress and job satisfaction in a sample of merchant seafarers.Results: While the structural equation model produced acceptable fit to the sample data according to numerous goodness-of-fit statistics, the comparative fit index and Tucker-Lewis index results indicated less than satisfactory model fit. The model explained 23.8% of variance in the criterion variable of perceived stress, and the strongest predictive effect was for dispositional resilience. The model explained 70.6% of variance in the criterion variable of job satisfaction, and the strongest predictive effect was for instrumental work support.Conclusion: When addressing the psychosocial well-being of merchant seafarers, findings of this study suggest that dispositional resilience may be a particularly important factor with regards to perceived stress, while instrumental work support appears to be a critical factor in relation to job satisfaction. Importantly, however, an overall work environment that is perceived by employees as supportive, equal and just is a cornerstone for the psychosocial well-being of seafarers.

The application of EquiFrame in the analysis of sexual and reproductive health policies by Ivanova et al to a new thematic area, their selection of only some of the Core Concepts of human rights in health service provision and the addition of new vulnerable groups relevant to the purpose of their analysis, are all very welcome developments. We also applaud their application of EquiFrame to policies in countries where it has not previously been used, along with their use of interviews with policy-makers to produce a deeper understanding of policy processes. We argue that clear justification for the inclusion of additional, or replacement of some exiting vulnerable groups within EquiFrame should be accompanied by clear definitions of such groups, along with the evidence-base that justifies their classification as a vulnerable or marginalised group. To illustrate the versatility of EquiFrame, we summarise a range of ways in which it has been used across a number of regions; including a brief Case Study of its use to develop the National Health Policy of Malawi. While EquiFrame focuses on policy content, we preview a new policy analysis tool – Equity and Inclusion in Policy Processes (EquIPP) – which assesses the extent of equity and inclusion in broader policy processes. Together, EquiFrame and EquIPP can be used to help governments and civil society ensure that policies are addressing the much stronger emphasis on social inclusion, now apparent in the Sustainable Development Goals (SDGs).

Abstract 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: 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.

This paper explores differences in experienced environmental barriers between individuals with and without disabilities and the impact of additional factors on experienced environmental barriers. Data was collected in 2011-2012 by means of a two-stage cluster sampling and comprised 400-500 households in different sites in South Africa, Sudan Malawi and Namibia. Data were collected through self-report survey questionnaires. In addition to descriptive statistics and simple statistical tests a structural equation model was developed and tested. The combined file comprised 9,307 participants. The Craig Hospital Inventory of Environmental Factors was used to assess the level of environmental barriers. Transportation, the natural environment and access to health care services created the biggest barriers. An exploratory factor analysis yielded support for a one component solution for environmental barriers. A scale was constructed by adding the items together and dividing by number of items, yielding a range from one to five with five representing the highest level of environmental barriers and one the lowest. An overall mean value of 1.51 was found. Persons with disabilities scored 1.66 and persons without disabilities 1.36 (F = 466.89, p < .001). Bivariate regression analyses revealed environmental barriers to be higher among rural respondents, increasing with age and severity of disability, and lower for those with a higher level of education and with better physical and mental health. Gender had an impact only among persons without disabilities, where women report more barriers than men. Structural equation model analysis showed that socioeconomic status was significantly and negatively associated with environmental barriers. Activity limitation is significantly associated with environmental barriers when controlling for a number of other individual characteristics. Reducing barriers for the general population would go some way to reduce the impact of these for persons with activity limitations, but additional and specific adaptations will be required to ensure an inclusive society.

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.

Background: Health policies have the potential to be important instruments in achieving equity in health. A framework – EquiFrame - for assessing the extent to which health policies promote equity was used to perform an equity audit of the health policies of three international aid organizations. Objective: To assess the extent to which social inclusion and human rights feature in the health policies of DFID (UK), Irish Aid, and NORAD (Norway). Method: EquiFrame provides a tool for analyzing equity and quality of health policies with regards to social inclusion and human rights. Each health policy was analyzed with regards to the frequency and content of a predefined set of Vulnerable Groups and Core Concepts. Results: The three policies vary but are all relatively weak with regards to social inclusion and human rights issues as defined in EquiFrame. The needs and rights of vulnerable groups for adequate health services are largely not addressed. Conclusion: In order to enhance a social inclusion and human rights perspective that will promote equity in health through more equitable health policies, it is suggested that EquiFrame can be used to guide the revision and development of the health policies of international organizations, aid agencies and bilateral donors in the future. Limitations: Analyses are limited to “policy on the books” and does not measure how effectively vulnerable groups are included in mainstream health policy work.

The World Report on Disability highlights some of the major challenges in the path to realisation of the rights of persons with disabilities as per the United Nations Convention. While the recently published guidelines on Community Based Rehabilitation show the way to address these challenges, effective implementation would require not only higher levels of investment in human resources, but also a significantly newer and different skill-set for the additional personnel. The authors suggest that a scientifically sophisticated, systematic and coordinated research programme, with global reach and participation, is needed for the establishment of a useful and robust evidence-base for Community Based Rehabilitation interventions. It is also suggested that the development of a new cadre of rehabilitation workers could be a key component of the programme, and could help to alleviate the extant crisis in human resources for health in many low-income countries.

Purpose: Despite a highly progressive legislation and clear governmental commitment, living conditions among persons with disabilities in Namibia are systematically lower than among persons without disabilities. This implies that persons with disabilities are denied equal opportunities to participate and contribute to society, and consequently are denied their human rights.Methods: EquiFrame, an innovative policy analysis framework, was used to analyse Namibian Policy on Orthopaedic Technical Services. EquiFrame evaluates the degree of stated commitment of an existing health policy to 21 Core Concepts of human rights and to 12 Vulnerable Groups, guided by the ethos of universal, equitable and accessible health services.Results: A number of Core Concepts of human rights and Vulnerable Groups were found to be absent in the Namibian Policy on Orthopaedic Technical Services, and its Overall Summary Ranking was assessed as Moderate.Conclusion and Implications: The Namibian health sector faces significant challenges in addressing inequities with respect to its policy on Orthopaedic Technical Services. If policy content, or policy ‘on the books’, is not inclusive of vulnerable groups and observant of core concepts of human rights, then health practices are also unlikely to do so. This paper illustrates that EquiFrame can provide the strategic guidance for the reform of Namibian Orthopaedic Technical Services policy, leading to universal and equitable access to healthcare.doi: 10.5463/dcid.v23i3.132

There is an increasing awareness among researchers and others that marginalized and vulnerable groups face problems in accessing health care. Access problems in particular in low-income countries may jeopardize the targets set by the United Nations through the Millennium Development Goals. Thus, identifying barriers for individuals with disability in accessing health services is a research priority. The current study aimed at identifying the magnitude of specific barriers, and to estimate the impact of disability on barriers for accessing health care in general. A population based household survey was carried out in Sudan, Namibia, Malawi, and South Africa, including a total of 9307 individuals. The sampling strategy was a two-stage cluster sampling within selected geographical areas in each country. A listing procedure to identify households with disabled members using the Washington Group six screening question was followed by administering household questionnaires in households with and without disabled members, and questionnaires for individuals with and without disability. The study shows that lack of transport, availability of services, inadequate drugs or equipment, and costs, are the four major barriers for access. The study also showed substantial variation in perceived barriers, reflecting largely socio-economic differences between the participating countries. Urbanity, socio-economic status, and severity of activity limitations are important predictors for barriers, while there is no gender difference. It is suggested that education reduces barriers to health services only to the extent that it reduces poverty. Persons with disability face additional and particular barriers to health services. Addressing these barriers requires an approach to health that stresses equity over equality.

HIV/AIDS in South Africa Edited by SS Abdool Karim and Q Abdool Karim. Cape Town: Cambridge University Press, 2005. ISBN-10 0-521- 61629-8 & ISBN-13 978-0-521-61629-4. Reviewed by Shandir Ramlagan.HIV/AIDS and Democratic Governance in South Africa: Illustrating the Impact on Electoral Processes By Per Strand, Khabele Matlosa,Ann Strode & Kondwani Chirambo, Institute for Democracy in South Africa (IDASA), Pretoria, South Africa, 2005. ISBN: 1-919798-80-3 Reviewed by Sarah Pugh.The Health of our Educators: Focus on HIV/AIDS in South African Public Schools Edited by O Shisana, K Peltzer,N Zungu-Dirwayi & JS Louw. Cape Town: HSRC, 2005 Reviewed by Malcolm MacLachlan.

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.

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.

Martin Gerdin and colleagues argue that disaster health interventions and decision-making can benefit from an evidence-based approach Please see later in the article for the Editors' Summary.

While many health services strive to be equitable, accessible and inclusive, peoples' right to health often goes unrealized, particularly among vulnerable groups. The extent to which health policies explicitly seek to achieve such goals sets the policy context in which services are delivered and evaluated. An analytical framework was developed--EquiFrame--to evaluate 1) the extent to which 21 Core Concepts of human rights were addressed in policy documents, and 2) coverage of 12 Vulnerable Groups who might benefit from such policies. Using this framework, analysis of 51 policies across Malawi, Namibia, South Africa and Sudan, confirmed the relevance of all Core Concepts and Vulnerable Groups. Further, our analysis highlighted some very strong policies, serious shortcomings in others as well as country-specific patterns. If social inclusion and human rights do not underpin policy formation, it is unlikely they will be inculcated in service delivery. EquiFrame facilitates policy analysis and benchmarking, and provides a means for evaluating policy revision and development.