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Disability-inclusive responses to COVID-19: Lessons learnt from research on social protection in low- and middle-income countries

Abstract Introduction Many refugees face challenges accessing water, sanitation, and hygiene (WASH) services. However, there is limited literature on WASH access for refugee populations, including for menstrual health services. Unmet WASH access needs may therefore be hidden, amplifying morbidity and mortality risks for already vulnerable refugee populations. The aim of this study was therefore to quantitatively analyze WASH access among refugee camps, with a focus on households with women of reproductive age. Methods This was a cross-sectional study that utilized the Standardized WASH Knowledge, Attitude and Practice (KAP) Survey. A total of 5632 household questionnaires were completed by the United Nations Refugee Agency in 2019 in 21 refugee camps and settlements in Bangladesh, Kenya, South Sudan, Uganda, and Zimbabwe. WASH access (14 items) and social and geographic stratifiers were analyzed at the household-level including the refugee camp, country of the settlement, having women of reproductive age, members with disability/elderly status, and household size. We calculated frequencies, odds ratios, and performed bivariate and multivariate analyses to measure inequalities. We developed a Female WASH Access Index to characterize WASH access for households with women of reproductive age. Results Most refugee households had high levels of access to improved water (95%), low levels of access to waste disposal facility (64%) and sanitation privacy (63%), and very low access to basic sanitation (30%) and hand hygiene facility (24%). 76% of households with women of reproductive age had access to menstrual health materials. WASH access indicators and the Female WASH Access Index showed large inequalities across social and geographic stratifiers. Households with disabled or elderly members, and fewer members had poorer WASH access. Households with women of reproductive age had lower access to basic sanitation. Conclusions Large inequalities in WASH access indicators were identified between refugee sites and across countries, in all metrics. We found high levels of access to improved water across most of the refugee camps and settlements studied. Access to basic hygiene and sanitation, sanitation privacy, waste disposal, and menstrual health materials, could be improved across refugee sites. Households with women of reproductive age, with 4+ members, and without members with disability/elderly status were associated with higher WASH access. The female WASH access index piloted here could be a useful tool to quickly summarize WASH access in households with women of reproductive age. 

/pdf/social-and-geographic-inequalities-in-water-sanitation-and-1luqd39p.pdf

Social and geographic inequalities in water, sanitation and hygiene access in 21 refugee camps and settlements in Bangladesh, Kenya, Uganda, South Sudan, and Zimbabwe

Background Adequate access to water, sanitation and hygiene (WASH) is imperative for health and wellbeing, yet people with disabilities, people with incontinence and people who menstruate often experience unmet WASH requirements. Methods In 2019 we completed a mixed-methods study in two provinces of Vanuatu, (SANMA and TORBA). The study comprised 1) a population-based disability survey using the Washington Group Short-Set 2) a nested case-control study to explore associations between WASH, disability and gender, and 3) an in-depth qualitative assessment of the experiences of WASH users with additional requirements: people with and without disabilities who menstruate, or experience incontinence. Finding 11,446 households (response rate 85%) were enrolled into the survey. All-age disability prevalence across the two provinces was 2.6% (95% Confidence Interval 2.5–2.8), increasing with age. 814 people with, and 702 people without disabilities participated in the case-control study. People with disabilities were statistically more likely to experience barriers in seven of eight intra-household indicators. WASH-related stigma, reliance on informal caregivers, and under-resourcing of WASH personnel were critical issues for people who menstruate or experience incontinence. Interpretation People with disabilities, people with incontinence and people who menstruate in Northern Vanuatu face continued challenges in accessing safe, affordable and appropriate WASH that meets their requirements. Outputs from this study have supported progression towards gender and disability-inclusive WASH programming in the area and highlighted the value of mixed-methods research. Funding The research was funded by the Australian Government's Water for Women fund and donations from the Australian public.

Water, women and disability: Using mixed-methods to support inclusive WASH programme design in Vanuatu.

While access to support for individuals with disabilities has attracted international attention, children with disabilities and their families continue to face a range of barriers that limit their timely access to the needed support, including health service. This is even worse for children with disabilities living in resource poor settings like Bangladesh. The objective of this study was to determine the extent to which families of children with disabilities have knowledge about and access to government support for their children with disabilities in Bangladesh. We employed a cross-sectional study among 393 families of children with disabilities who sought services from the Centre for the Rehabilitation of the Paralysed for their children with disabilities in Bangladesh. We used chi-square test to measure the association between categorical variables and, Mann-Whitney U-test to compare mean across different sub-groups. Overall, family members of children with disabilities have limited knowledge about and access to government support. We found a significant association between knowledge and access to government support (p<0.001). Family members with children with disabilities aged younger than six years had less access to government support (p<0.001). We thus concluded with an urgent call on government agencies and service providers to provide relevant and timely information to families of children with disabilities to enable them to access the needed support.

/pdf/exploring-access-to-government-led-support-for-children-with-4qgxhraolg.pdf

Exploring access to government-led support for children with disabilities in Bangladesh

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

/pdf/are-current-approaches-for-measuring-access-to-clean-water-3vrghx0bi8.pdf

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

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

https://www.tandfonline.com/doi/pdf/10.1080/13600818.2021.1985988

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

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

/pdf/access-to-social-protection-among-people-with-disabilities-3dz6t1jpdm.pdf

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

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

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

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