Ijerph 15 02165 v2

International Journal of
Environmental Research
and Public Health
Review
A Systematic Review of Access to Rehabilitation for
People with Disabilities in Low- and
Middle-Income Countries
Tess Bright * , Sarah Wallace and Hannah Kuper
International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, London WC1
E7HT, UK; [email protected] (S.W.); [email protected] (H.K.)
* Correspondence: [email protected]

Received: 10 August 2018; Accepted: 27 September 2018; Published: 2 October 2018
Abstract: Rehabilitation seeks to optimize functioning of people with impairments and includes
a range of specific health services—diagnosis, treatment, surgery, assistive devices, and therapy.
Evidence on access to rehabilitation services for people with disabilities in low- and middle-income
countries (LMICs) is limited. A systematic review was conducted to examine this in depth.
In February 2017, six databases were searched for studies measuring access to rehabilitation among
people with disabilities in LMICs. Eligible measures of access to rehabilitation included: use of
assistive devices, use of specialist health services, and adherence to treatment. Two reviewers
independently screened titles, abstracts, and full texts. Data was extracted by one reviewer and
checked by a second. Of 13,048 screened studies, 77 were eligible for inclusion. These covered a broad
geographic area. 17% of studies measured access to hearing-specific services; 22% vision-specific;
31% physical impairment-specific; and 44% measured access to mental impairment-specific services.
A further 35% measured access to services for any disability. A diverse range of measures of disability
and access were used across studies making comparability difficult. However, there was some
evidence that access to rehabilitation is low among people with disabilities. No clear patterns were
seen in access by equity measures such as age, locality, socioeconomic status, or country income
group due to the limited number of studies measuring these indicators, and the range of measures
used. Access to rehabilitation services was highly variable and poorly measured within the studies in
the review, but generally shown to be low. Far better metrics are needed, including through clinical
assessment, before we have a true appreciation of the population level need for and coverage of
these services.
Keywords: access; health care; rehabilitation; people with disabilities; low- and middle-income
country; universal health coverage
1. Introduction
The World Health Organization (WHO) estimates that over one billion people, or 15% of the
global population, live with a disability, with 80% living in low- and middle-income countries
(LMICs) [1]. Disability, defined by the International Classification of Functioning, Disability and
Health (ICF), is an umbrella term for impairments, activity limitations, and participation restrictions [2].
People with disabilities experience an impairment (e.g., visual impairment) because of a health
condition (e.g., glaucoma). Contextual factors, both at the individual (e.g., age, sex) and wider societal
level (e.g., access to health services, attitudes towards disability), play a crucial role an individual’s
experience of the impairment.
People with disabilities often experience poorer levels of health than people without disabilities
for various reasons [1]. By definition, people with disabilities have an underlying health condition
Int. J. Environ. Res. Public Health 2018, 15, 2165; doi:10.3390/ijerph15102165 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2018, 15, 2165 2 of 34
which causes greater health needs. For example, people with chronic health conditions such as arthritis
have regular ongoing health needs relating to the health condition and associated impairment [1].
People with disabilities may also be at risk of developing secondary health conditions such as
depression [3]. Furthermore, evidence from a range of settings, both high-income countries and LMIC,
suggests that people with disabilities face a multitude of barriers to accessing healthcare services.
Poverty and disability are linked in a cycle, whereby poverty can lead to disability, and disability to
poverty [4]; poverty and poor health are known to be linked through various mechanisms including
though poorer living conditions, lifestyle factors (e.g., diet, smoking), and access to health services.
People with disabilities have a need to access the same general health care services as people
without disabilities such as care-seeking when ill, vaccinations, and HIV treatment. In addition to
general health services, people with disabilities also may require specific health care services related
to their impairment, which includes rehabilitation. Rehabilitation is a broad term that encompasses
a set of interventions to address impairments—activity limitations, and participation restrictions,
as well as personal and environmental factors that have an impact on functioning [1]. Rehabilitation
seeks to optimize functioning of people experiencing disabilities. Therefore, it includes the range
of specific health services people with disabilities may require, from diagnosis, treatment, surgery,
assistive devices, and therapy.
Evidence on access to rehabilitation services is sparse; however, there is expected to be very
limited capacity to meet demand for these services in LMIC. The WHO estimates that there are
less than ten skilled rehabilitation practitioners per 1 million population in LMIC [5]. Furthermore,
the WHO estimates that between 5 and 15% of people in need for assistive devices in LMIC have
received them [6]. Even fewer are expected to have hearing aids, with less than 3% of hearing aid
need being met [7]. However, as is recognized in the WHO’s World Report on Disability, global data
on unmet need for rehabilitation services is extremely sparse [1]. Unmet need for rehabilitation has
a substantial impact on activity limitations, participation restrictions, and can result in poorer health
and quality of life [1].
Rehabilitation has previously received little attention from governments, which has contributed
to poor service availability and lack of co-ordination between services. Affordable and high-quality
services should be available to all those in need. This is the main premise behind Universal
Health Coverage (UHC), which is defined as, “ensuring all people have access to needed promotive,
preventive, curative, rehabilitative, and palliative services they need, of sufficient quality to be effective,
while ensuring that the use of these services does not expose the user to financial hardship” [8]. UHC is
recognized as a key target in Goal 3 of the Sustainable Development Goals (SDGs) (Ensure healthy
lives and promote well-being for all at all ages) [9], and so access to rehabilitation is essential in order
to reach the SDG goals and targets. Access to rehabilitation for people with disabilities is also a human
right, as stated in Article 26 of United Nations Convention for the Rights on People with Disabilities
(UNCRPD) [10].
Recent global initiatives such as the Global Co-operative on Assistive Health Technology (GATE)
strive for affordable and high-quality assistive technologies to be available for all those in need [11].
In February 2017, the WHO hosted a stakeholder meeting Rehabilitation 2030: A call to action,
highlighting the issue of the substantial unmet need for rehabilitation around the world, and the lack
of data on access to rehabilitation [5]. Considering the lack of data, we conducted a systematic review
which aimed to summarize the current literature on access to rehabilitation for people with disabilities
in LMIC, with a focus on health-related rehabilitation.
2. Materials and Methods

The systematic search was conducted in February 2017 for peer-reviewed articles that presented
research findings on access to rehabilitation for people with disabilities in LMIC settings. The Preferred
Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was followed for
conducting and reporting the review [1].
2.1. Eligibility Criteria

Studies were eligible if they met the following criteria: (1) quantitative research that included
people with disabilities; (2) results reported access to rehabilitation for people with disabilities; and
(3) research was undertaken in a LMIC as defined by the World Bank country classification 2017.
No restrictions were placed on publication date, or language. Studies were excluded if the full text
was not available after exhausting all possible sources. Duplicate reports from the same study were
either combined if they reported different result or one was excluded if the results were the same.
2.2. Access to Rehabilitation Defined

For this review access was defined as use and coverage of services. Rehabilitation was defined
in relation to the WHO definition as a “set of measures that assist individuals who experience
or are likely to experience, disability to achieve and maintain optimal functioning in interaction
with their environments” [1]. Using this definition, a broad range of interventions that may be
required to maximize functioning were included: access to medical rehabilitation, access to therapy,
coverage of assistive devices, and adherence to medication. Medical rehabilitation is defined as
improving functioning through the diagnosis and treatment for health condition, reducing impairments
and preventing or treating complications. Therapy is defined as restoring or compensating for
loss of functioning, and preventing deterioration in functioning which may include physiotherapy,
occupational therapy, and speech therapy. Assistive devices are defined as any equipment that is
used to increase or maintain functional capabilities. We did not include studies measuring curative
interventions, such as provision of spectacles, cataract surgery, hip replacement surgery, and similar
treatments [12–14]. Whilst we recognize that rehabilitation extends beyond specialist health-related
needs, this was beyond the scope of our review, which focused on health-related rehabilitation.
2.3. Types of Disability Measures

Studies defining disability using both the ICF definition (e.g., functioning, or activity limitations,
and participation restrictions) and medical model definitions (i.e., specific impairments or disorders)
were included.
2.4. Information Sources

Six databases (EMBASE, Global Health, CINAHL, Web of Science, MEDLINE, and PSYCINFO)
were searched. The search strategy used key words for the following concepts: LMICs, people with
disabilities, and access to health services. Terms were developed using MeSH or equivalent as well
as from other reviews on similar topics. Boolean, truncation, and proximity operators were used to
construct and combine searches for the key concepts as required for individual databases. An example
of the search strategy is provided as Table S1. Systematic reviews identified through the search were
reviewed for relevant included studies. If study protocols were identified, a search was made to
determine whether the results of the study had been published. Furthermore, studies known to
authors were included. No restrictions were made on language or time of publication.
2.5. Study Selection

All studies identified through the search process were exported to an EndNote database
(version X7, Clarivate Analytics, Philadelphia, PA, USA) for removal of duplications and screening.
Two reviewers (Tess Bright and Hannah Kuper) independently examined the titles, abstracts,
and keywords of electronic records according to the eligibility criteria. Results were compared.
The full texts were double screened (Tess Bright and Hannah Kuper) according to the eligibility criteria
for final inclusion in the systematic review. Any disagreements in the selection of the full text for
inclusion were resolved through discussion.
2.6. Data Collection Process

Data were extracted in to a Microsoft Excel database developed for the purposes of this review.
The first author (Tess Bright) extracted all data and this was independently examined by a second
reviewer to ensure accuracy (Sarah Wallace). Data were extracted on the following study components:
• General study information, including author, year of publication

• Study design, sampling, and recruitment methods
• Study setting, and dates conducted
• Population characteristics including age, sex, and sample size
• Disability type/domain being studied, and means of assessing disability
• Results: main findings related to access to rehabilitation and any disaggregation by age,
sex, urban-rural status, or other variables. We extracted data on the proportion covered by
rehabilitation services in the population. Where unmet need was presented, we calculated the
met need as one minus the unmet need.
We conducted a narrative synthesis due to the variation in included study designs, measurement
of disability and outcomes which made meta-analysis impossible.
2.7. Risk of Bias in Individual Studies

Quality assessments of all eligible studies were carried out independently by two reviewers (Tess
Bright and Sarah Wallace). We evaluated studies based on a set of criteria according to the SIGN50
guidelines [15]. Table 1 outlines the criteria used to evaluate studies.
Table 1. Quality assessment criteria and ratings.
Assessment Criteria
• Study design, sampling method is appropriate to the study question
• Adequate sample size (>100 participants), or sample size calculations undertaken
• Response rate reported and acceptable (>70%)
• Disability/impairment measure is clearly defined and reliable
• Measure of access clearly defined and reliable
• Potential confounders taken into account in analysis (if necessary)
• Confidence intervals are presented
Overall Ratings
Low risk of bias: All or almost of the above criteria
++ were fulfilled, and those that were not fulfilled were
thought unlikely to alter the conclusions of the study
Medium risk of bias: Some of the above criteria were
+ fulfilled, and those not fulfilled were thought unlikely
to alter the conclusions of the study
High risk of bias: Few or no criteria were fulfilled,
−− and the conclusions of the study were thought likely
or very likely to alter with their inclusion
3. Results
3.1. Study Selection

8886 unique records were identified through electronic searches. 8609 studies were excluded
during title and abstract screen, resulting in 278 for the full text screen. Following full text review,
201 studies were excluded, and the full text could not be identified for 14 articles (Figure 1).
Consequently, 77 studies were selected for inclusion and provided data for 106,462 people with
disabilities across 64 countries.
Int. J. Environ. Res. Public Health 2018, 15, x 5 of 36
results. (LMIC: Low- and Middle-Income Countries).

Figure 1. Flow chart of search results. Countries).
3.2.
3.2. Study
Study Characteristics
Characteristics
Table
Table 22 summarizes
summarizes the the characteristics
characteristics ofof the
the studies
studies eligible
eligible for
for inclusion.
inclusion. ByBy region,
region, most
most
studies were conducted in sub-Saharan Africa (31%), followed by South Asia
studies were conducted in sub-Saharan Africa (31%), followed by South Asia (18%), Latin America (18%), Latin America
(16%),
(16%), East
East Asia
Asia (16%),
(16%), Middle
Middle East
East (9%),
(9%), and
and Europe
Europe (3%).
(3%). A A further
further 8%
8% were
were conducted
conducted in in multiple
multiple
countries.
countries. In terms of location, 49% were conducted in both urban and rural areas, with 18% in urban
In terms of location, 49% were conducted in both urban and rural areas, with 18% in urban
only
only and
and 13%
13% in in rural
rural only
only (location
(location unclear
unclear for
for 19%
19% of
of studies).
studies). Most
Most studies
studies (73%)
(73%) were
were conducted
conducted
at
at subnational
subnational (e.g.,
(e.g., district(s),
district(s), or
or provincial
provincial level),
level), with
with the
the remaining
remaining 27% 27% carrying
carrying out
out national
national
surveys. Over half of studies were conducted in 2010 or later (53%). The vast
surveys. Over half of studies were conducted in 2010 or later (53%). The vast majority of studies majority of studies
were
were cross-sectional surveys (82%) with the remaining studies using cohort
cross-sectional surveys (82%) with the remaining studies using cohort (5%), case control (10%)(5%), case control (10%)
or
or retrospective
retrospective longitudinal
longitudinal (3%)(3%) study
study designs.
designs. In terms
In terms of country
of country income
income group,
group, 33%
33% of of studies
studies were
were conducted
conducted in low in low income,
income, 28%28% in low-middle
in low-middle income,
income, 29%29% ininupper-middle
upper-middleincomeincomeandand 8%8% in
in
countries of varying income levels.
countries of varying income levels.
Table 2. Characteristics of included studies.
Variable Number %
Region
Latin America/Caribbean 12 16%
East Asia/Pacific 12 16%
Sub-Saharan Africa 24 31%
Middle east 7 9%
South Asia 14 18%
Europe/Central Asia 2 3%
Various 6 8%
Country income group
Low 26 33%
Low-middle 22 28%
Upper-middle 23 29%
Various 6 8%
Location
Urban 14 18%
Rural 10 13%
Both 38 49%
Unclear 15 19%
Decade of publication
1990–1999 11 14%
2000–2009 25 32%
2010–current 41 53%
Age of participants
All ages 29 38%
Adults only 25 32%
Older adults 7 9%
Children only 11 14%
Unclear age/not presented 5 6%
Study design
Cross-sectional 63 82%
Retrospective longitudinal
2 3%
study
Case control study 8 10%
Cohort 4 5%
Disability domain
Hearing 13 17%
Vision 17 22%
Physical 24 31%
Mental 34 44%
Any disability 27 35%
Multiple domains 29 38%
3.3. Participants
Most studies included people of all ages (38%). 32% included adults only, 9% included older
adults (>40 years), and 14% included children only (<18 years). In 6% of studies the age group was
unclear. Considering disability domain, a large proportion of studies measured access outcomes
related to mental impairment (44%), which we defined according to the International Classification
of Diseases 10 (ICD10) “mental and behavioral disorders” included mental illnesses, intellectual
impairment, and developmental delay. Epilepsy, although a neurological condition according to ICD10
was also grouped under mental impairment for simplicity. The remainder considered services related
to hearing impairment (17%) visual impairment (22%), physical impairment (31%) or disability in
general, across multiple domains (31%). The method of assessment of disability varied across studies,
with 33 using self-reported measures (11 used the Washington Group short or extended set), 31 studies
used clinical examination, four used a combination of reported and clinical measures, two used registry
data, in two studies assessment methods were unclear, and the remaining three studies used alternative
methods (e.g., community health worker report).
3.4. Outcome Types

Types of rehabilitation outcomes included:
• Medical rehabilitation: including received treatment/surgery, received diagnosis, access to, or ever
received rehabilitation (any type), received therapy (physical, occupational, speech and language)
(48 studies, 62%)
• Assistive devices: including hearing aids, mobility aids, low vision devices, or any assistive device
(25 studies, 32%)
• Adherence: including adherence to treatment, treatment completion rate, and uptake of referral
(25 studies, 32%)
In addition, data on barriers to accessing rehabilitation for people with disabilities were extracted
as secondary outcomes in 23 studies (30%).
3.5. Description of Studies

Results of the 77 included studies are presented below by access to services specific to the
following disability domains: hearing, mental health, physical, and visual. Where multiple domains
were measured, and access outcomes were not disaggregated by domain, the results are presented in a
separate section on rehabilitation for any disability.
3.5.1. Access to Rehabilitation for Hearing Impairment

In total, 13 studies measured access to hearing specific services in 12 LMIC countries, and four
World Bank regions. The study populations used to assess access varied across studies, with the
majority using population-based data; however, one sampled children from deaf schools, two from
registries and one from a clinic. Most studies in this group (seven studies) were conducted among
people of all ages. Five studies were conducted in children, and two among older adults. The method
of assessment varied, with five using the Washington Group short or extended set, one using the WHO
‘Ten Questions’, three using a bespoke self-reported tool, two conducting clinical assessments, and the
remaining two using other methods (registry, community health worker identification). The access
results are thus not directly comparable. Results are outlined in Table 3. Overall, nine studies
measured coverage of assistive devices, seven studies measured access to medical rehabilitation,
and one measured adherence. Coverage of assistive devices ranged from 0–66% across studies.
General rehabilitation coverage (i.e., access to hearing services) was between 3–62%. Finally, one study
measured adherence/compliance with referral and estimated this to be 34%.
Across studies, no clear patterns of access were seen by country group, locality, or by age.
Coverage of assistive devices tended to increase with country income group but was typically quite
low. One national study by Malta et al. (2016) in Brazil measured association between locality (urban or
rural) and access and found a higher proportion had assistive devices in urban areas compared to rural
areas. In terms of the quality of the evidence across studies, most studies were judged to have low
risk of bias (eight studies). Six studies were judged to have high or medium risk of bias due to small
sample size (three studies), means of assessing disability unreliable (three studies), or poor response
rate (two studies).
Table 3. Access to hearing impairment specific services (D = disability).

Proportion Covered by Type of
Country World Country Locality Means of Rehabilitation (%)
Study Author, Income Study Type Participant Age
(Study Bank (Urban or N (%D) Assessing Outcome Risk of Bias
Year Source Adherence
Location) Region Group Rural) Disability Medical Assistive
to
Rehabilitation Devices
Treatment
Self-report Medium: adequate
Zimbabwe 278 (NS); 55 (20%) (bespoke tool, but sample size, but small
Allain et al. Cross-sectional Older Wearing hearing
(Bindura, SSA Low income Both Population with hearing unclear method) - 0 - number with hearing
(1997) [16] study adults aids when needed
Marondera) impairment and observation loss, and unclear how
by nurses hearing loss assessed
Coverage of
hearing aids
(proportion of
Bernabe-Ortiz Peru Upper-middle Case control All Washington Medium: low response
SSA Semi-urban Population 322 (50%) those who use - 9 -
et al. (2016) [17] (Morropon) income study ages Group short set rate
hearing aids among
those reported in
need)
Met need for
Danquah et al. Haiti Case control All Washington
LA Low income Urban Population 356 (50%) medical 3 3 - Low
(2015) [18] (Port-au-Prince) study ages Group short set
rehabilitation
Proportion of
Devendra et al. Malawi Case control WHO ten children who
SSA Low income Unclear Clinic 592 (50%) Children 14 - - Low
(2013) [19] (Lilongwe) study questions attended ear clinic
of those in need
Coverage of
hearing aids
Tanzania (proportion of
Kuper et al. Case control All Washington
(Mbeya, SSA Low income Both Population 807 (39%) those who use - 0 - Low
(2016) [20] study ages Group short set
Tanga, Lindi) hearing aids among
those reported in
need)
% needing hearing
Maart et al. South Africa Upper-middle Cross-sectional All Washington
SSA Urban Population 151 (100%) therapy that 42 - - Low
(2013) [21] (Cape Town) income study ages Group short set
received
Cameroon
(Fundong Low-middle Washington
Mactaggart et SSA Case control 845 (60%) All Coverage of - 24 - Low
Health income Unclear Population
al. (2015) [22] study ages Group extended hearing aids
District) set and clinical
India Low-middle assessment
SA 703 (61%) - 6 - Low
(Mahbubnagar) income
Attendance at
Malta et al. Brazil Upper-middle Cross-sectional All Self-report rehabilitation 8 (9 urban, 4
LA Both Population 204,000 (NS) - - Low
(2016) [23] (National) income study ages (bespoke tool) services for those in rural)
need
Table 3. Cont.
Uptake/compliance
with referral for
Bangladesh assistive device,
Nesbitt et al. Prospective Clinical
(Natore, SA Low income Both Population 1308 (100%) Children therapy, further - - 34 Low
(2012) [24] cohort study assessment
Sirajgani) investigation,
medicine, or
surgery
Visit for hearing
assessment
Omondi et al. Kenya Cross-sectional Deaf Clinical High: small sample
SSA Low income Both 33 (100%) Children (diagnosis); hearing 27 0 -
(2007) [25] (Kisumu) study schools assessment size
aid use (assistive
device)
Households of
children with
Use of Medium: small sample
Padmamohan Low-middle Cross-sectional disabilities were
India (Kerala) SA Rural Population 98 (100%) Children rehabilitation 16 - - size; unclear measure
et al. (2009) [26] income study identified with
treatment of disability
community
health workers
Had hearing test
Ribas et al. Brazil Upper-middle Cross-sectional Older Self-report (diagnosis); wore Low: unreliable
LA Rural Clinic 578 (32%) 28 16 -
(2015) [27] (Curibita) income study adults (bespoke tool) hearing aids measure of disability
(assistive device)
Coverage of
hearing aids
High: poor response
Tan et al. (2015) Malaysia Upper-middle Cross-sectional (assistive devices);
EAP Unclear Registry 305 (100%) Children Registry 62 66 - rate, and unreliable
[28] (Penang) income study proportion
measure of disability
accessing hearing
services)
SSA: sub-Saharan Africa, LA: Latin America, SA: South Asia, EAP: East Asia & Pacific.
3.5.2. Access to Rehabilitation for Mental Impairment

In total, 34 studies measured access to specialist health services for people with mental
impairments in 17 countries across six World Bank regions. Three studies were multi-country studies,
for which it was possible to disaggregate results by country. For several countries, multiple studies
were identified—three in China, three in Lebanon, four in Mexico, five in India, four in South Africa and
four in Brazil. Considering age, the majority were conducted among adults (19 studies), among people
of all ages, four among children, and one among older adults. Most studies sampled participants from
the population (28 studies); the remaining sampled from schools (one study), clinic (three studies), or a
variety of sources (two studies).
This category encompasses a broad range of conditions, from depression to intellectual
impairment. Our search identified nine studies focusing on depression (or major depressive
disorder), four studies on schizophrenia, three on epilepsy, five studies on psychiatric disorders,
14 measured general mental disorders with quite varied measures of assessment, two studies
measured unspecified mental health conditions and the remaining two studies focused on intellectual
impairment. In terms of method of assessment, a wide range of tools were used: five used a clinical
diagnosis/examination, eight used the WHO composite international diagnostic interview, five used
other validated questionnaires or tools (e.g., DSM-IV), two used the Washington Group short set,
two used other validated self-reported tools, eight used bespoke self-reported tools (three of these
combining with a clinical screen), one used household report, and one used global burden of disease
data (see Table 4 for details).
In terms of outcomes, 28 measured access to medical rehabilitation, and five measured adherence
to treatment. Access to medical rehabilitation for depression, which included treatment coverage
and use of mental health services, most ranged from 0% for males in Mexico (subnational) to 54% in
Brazil (national). El Sayed et al. (2015) found 65% of people with depression were in treatment across
various LMIC using nationally representative data from the World Health Surveys. For schizophrenia,
treatment coverage ranged from 50–71% in India (both subnational studies). Two multi-country studies
were conducted, the first by Lora et al. (2012) found coverage of 11% (low income countries) to 31%
(low-middle income countries) using the WHO Assessment Instrument for Mental Health Systems and
the second by El Sayed et al. (2015) found coverage of 67% World Health Survey data. Coverage of
epilepsy treatments ranged from 0% for older adults in Zimbabwe (subnational), to 52% among people
of all ages in The Gambia (subnational). For children with intellectual disabilities coverage was higher:
73% in Ethiopia (subnational) and 87% in India (subnational) (two studies only). For other less specific
conditions, coverage of medical rehabilitation ranged from 1% in China (national) (use of services, all ages)
to 68% for adults in South Africa (subnational) (percent needing rehabilitation who received, all ages).
The broad range of conditions, source of participants, outcomes, and age groups mean that
estimates within this group cannot be directly compared. However, it was clear that access for all
outcomes was quite low across studies, except for children with intellectual impairments. There was
considerable variation, even within studies conducted in the same country.
Across studies, no clear pattern was seen by country income level, locality or by age. One study
by Lora et al. (2012) found lower treatment coverage in low income countries (11%) compared to
low-middle income countries (31%). Considering other equity indicators, Li et al. (2013) and El Sayed
et al. (2015) found higher coverage for insured people. Hailemariam et al. (2012) Andersson et al.
(2013), Chikovani et al. (2015), Andrade et al. (2002) found no significant difference in access by
employment, or income, while Ma et al. (2012) and Raban et al. (2010) found that poorer people were
less likely to continue treatment. Demyttenaere et al. (2004) found an increase in coverage with severity
of impairment in Colombia, Iraq, Lebanon, Mexico, Nigeria, and Ukraine, but not in other countries.
In terms of the quality of the evidence, the vast majority of studies included in this group were
judged to have low risk of bias (30 studies). Three studies had high or medium risk of bias due to
small sample size (three studies), unclear or low response rate (four studies), or unreliable means of
assessing disability (five studies).
Table 4. Results for studies measuring mental impairments (D = disability).
Country World Proportion Covered by

Study Author, Country Locality Participant Age Specific Method of
(Study Bank Study Type N (%D) Outcome Rehabilitation Type % Risk of Bias
Year Income (Urban/Rural) Source Group Condition Assessment
Location) Region Medical Adherence to
Rehabilitation Treatment
Studies measuring mental health and psychiatric disorders
Screening Receipt of
0
Abas et al. Zimbabwe Low Cross-sectional Depression and questionnaire and antidepressant Medium: small sample
SSA Urban Population 51 (100%) Adults (antidepressant) -
(1997) [29] (Harare) income study anxiety clinical or size
10 (anxiolytic)
examination anxiolytic
India Proportion
Alekhya et al. Cross-sectional Medium: unclear
(Andhra SA Low-middle Both Clinic 103 (100%) Adults Depression Clinical diagnosis with good - 30
(2015) [30] study measure of disability
Pradesh) adherence
Proportion
DSM-IV schedule of those
South Africa
Andersson et al. Cross-sectional (mini international emotionally
(Eastern SSA Upper-middle Both Population 977 (31%) Adults Depression 43 - Low
(2013) [31] study neuropsychiatric troubled
Cape)
review) who sought
care
World Mental
Health Survey Visiting
version of the health
Hailemariam et Ethiopia (9 Low Cross-sectional
SSA Both Population 449 (100%) Adults Depression Composite facilities for 23 - Low
al. (2012) [32] regions) income survey
International depressive
Diagnostic episodes
Interview
WHO World
Mental Health
Snyder et al. Mexico Cross-sectional Composite Treatment Male 0;
LA Upper-middle Rural Population 945 (6.2%) Adults Depression - Low
(1999) [33] (Jalisco) study International received Female 13.0
Diagnostic
Interview
Lebanon Consulted
(Bejjeh, doctor;
Diagnostic
Kornet consulted
Karam et al. Cross-sectional Major depressive Interview Schedule Medium: risk of recall
Shehwan, ME Upper-middle Unclear Population 213 (100%) Adults other 23; 6; 30 -
(1994) [34] study disorder (DIS) by bias
Ashrafieh, professional;
psychologists
Ain treatment
Remmaneh) received
Self-report
Population Currently
Cross-sectional, (bespoke tool)
Fujii et al. Brazil (identified Major depressive taking High: risk of selection
LA Upper-middle Both web-based 9789 (10%) Adults followed by 54 -
(2012) [35] (National) through disorder prescription bias
survey validated
the web) medication
questionnaire
Proportion
48 LMICs Cross-sectional
in
El Sayed et al. (various study (World Depression and Self-report
Various Various Both Population 197,914 (NS) Adults treatment: 65; 67 - Low
(2015) [36] National level Health schizophrenia (bespoke tool)
depression,
surveys) Surveys)
schizophrenia
Table 4. Cont.
India (Assam,
Karnataka, Treatment
Medium: means of
Raban et al. Maharashtra, Cross-sectional Depression and Self-report coverage:
SA Low-middle Both Population 9994 (NS) Adults 12; 50 - assessing disability not
(2010) [37] Rajasthan, study schizophrenia (validated tool) depression;
reliable
Uttar Pradesh, schizophrenia
West Bengal)
Family report using
screening tool, and Ever
Padmavathi et India Low Cross-sectional All
SA Urban Population 261 (100%) Schizophrenia detailed received 71 - Low
al. (1998) [38] (Madras) income study ages
examination by a treatment
psychiatrist
Global burden of
Treatment
disease data for
coverage 11 (Low
prevalence of
Lora et al. 50 LMICs Cross-sectional (psychiatrist, income); 31
Various Various Unclear Various Unclear Adults Schizophrenia schizophrenia, and - Low
(2012) [39] (National) survey mental (Low-middle
number of people
health income)
who received care
professionals)
(facility level data)
Beijing: mild
China Sought 2; serious: 12
EAP Low-middle Urban 1628 (21%) - Low
(National) WHO composite treatment Shanghai:
international for serious: 0.5
Demyttenaere Cross-sectional
Population Adults Mental disorders diagnostic
et al. (2004) [40] Nigeria Low study condition in
SSA Urban 1682 (14%) interview (WMH, 10 - Low
(National) income the past 12
CIDI) months:
Mild 7
Ukraine mild;
EU Low-middle Both 1720 (56%) Moderate 17 - Low
(National) moderate;
Serious 19
serious
Mild 4.5
Lebanon
ME Upper-middle Both 1029 (47%) Moderate 10 - Low
(National)
Serious 15
Mild 8
Colombia
LA Low-middle Urban 2442 (33%) Moderate 12 - Low
(National)
Serious 24
Mild 10
Mexico
LA Upper-middle Urban 2362 (30%) Moderate 19 - Low
(National)
Serious 20
Received
specialty
WHO World
medical
Mental Health
care: any
Andrade et al. Brazil (Sao Case control Composite
LA Upper-middle Urban Population 1464 (27%) Adults Mental disorders disorder; 13; 23; 20; 10 - Low
(2002) [41] Paulo) study International
mood;
Diagnostic
anxiety;
Interview
substance
use
WHO World
Care
Mental Health Total
seeking for
Caraveo et al. Mexico Cross-sectional Mental health Composite proportion Medium: response rate
LA Upper-middle Urban Population 1937 (8.3%) Adults mental -
(1999) [42] (Mexico City) study condition International seeking help lower than 70%
health
Diagnostic < 50%
condition
Interview
Table 4. Cont.
Ever
Loeb et al. Malawi Low Cross-sectional All Mental/emotional Self-report received
SSA Both Population 1574 (100%) 22 - Low
(2004) [43] (National) income study ages difficulties (bespoke tool) rehabilitation
(medical)
Ever
Difficulties
Eide et al. Zambia Low Cross-sectional All Washington Group received
SSA Both Population 2865 (100%) remembering, 30 - Low
(2006) [44] (National) income study ages short set rehabilitation
concentrating
(medical)
Any health
care
Questionnaire
Alhasnawi et al. Iraq Cross-sectional treatment
ME Low-middle Both Population 4332 (14.5%) Adults Mental disorders based on ICD10 3; 4; 17 - Low
(2009) [45] (National) study (mild;
and DSM-IV
moderate;
serious)
Self-report
Use of
(bespoke tool)
Li et al. (2013) China Cross-sectional All services:
EAP Upper-middle Both Population 2.6 million (0.6%) Mental disorders followed by clinical 1; 40 - Low
[46] (National) study ages rehabilitation;
examination and
medication
WHO DAS
Proportion
needing
Maart et al. South Africa Cross-sectional All Difficulties Washington Group
SSA Upper-middle Urban Population 151 (100%) treatment 68 - Low
(2013) [21] (Cape Town) study ages remembering short set
who
received
Attendance
Mental
Malta et al. Brazil Cross-sectional All Self-report at
LA Upper-middle Both Population 20,400 (6%) impairment 30 - Low
(2016) [23] (National) study ages (bespoke tool) rehabilitation
(unspecified)
services
Georgia Population Self-report Self-reported
Chikovani et al. (conflict Cross-sectional (conflict Mental (bespoke) and problem
EU Upper-middle Unclear 3600 (30%) Adults 39 - Low
(2015) [47] affected study affected impairment validated clinical and sought
areas) areas) tools care
Support High: low response
Trump et al. South Africa Cross-sectional group All Self-report Compliance rate, means of
SSA Upper-middle Both 331 (100%) Mental disorders - 32
(2006) [48] (National) study members, ages (bespoke tool) (self-report) assessing disability
leaders unreliable
6 LMICs
Treatment
(regional:
prevalence
Colombia,
by type of
Mexico, Self-report
Ormel et al. Cross-sectional impairment:
China; Various Various Both Population 73,441 (NS) Adults Mental disorders (Chronic disorders 8 - Low
(2008) [49] study mental
national: checklist)
disorders
Lebanon,
(visiting a
South Africa,
professional)
Ukraine)
World Health Sought
Organization treatment
Seedat et al. South Africa Cross-sectional (WHO) Composite for
SSA Low-middle Both Population 4317 (NS) Adults Mental disorders 25 - Low
(2009) [50] (National) study International condition in
Diagnostic the past 12
Interview months
Table 4. Cont.
Adherence
Ma et al. (2012) China Population, Psychiatric
EAP Upper-middle Urban Cohort study 1386 (100%) Adults Clinical diagnosis to - 95 Low
[51] (Guangdong) hospitals disorders
medication
WHO World
Care
Mental Health
seeking for
Caraveo et al. Mexico Cross-sectional All Psychiatric Composite Medium: response rate
LA Upper-middle Urban Population 2857 (28.7%) mental 14 -
(1997) [52] (Mexico City) study ages disorders International lower than 70%
health
Diagnostic
condition
Interview
Mental
health
service use
in past 12
Brazil (North, months:
Validated tool
Paula et al. Northeast, Cross-sectional Psychiatric affective; 20; 17; 20; 9; 0;
LA Upper-middle Both Schools 1721 (12%) Children (KSADS-PL) based - Low
(2014) [53] Central, study disorders anxiety; 30
on caregiver report
Southeast) disruptive;
eating;
psychotic
disorder;
co-morbidity
Psychiatric
morbidity Compliance
Chadda et al. Low Retrospective All (schizophrenia, with High: small sample
India (Delhi) SA Not clear Clinic 80 (100%) Clinical diagnosis - 97
(2000) [54] income study ages bipolar, treatment size
unspecified regimen
psychosis)
WHO UNHCR
Treatment
Assessment
coverage
Schedule of Serious
Lebanon (Burj (received
Llosa et al. Cross-sectional Psychiatric Symptoms in Medium: Low
el-Barajneh ME Upper-middle Urban Population 194 (45%) Adults psychological 6 -
(2014) [55] study disorders Humanitarian response rate
refugee camp) or
Settings (WASSS),
psychiatric
followed by clinical
care)
exam
Results of studies measuring intellectual impairment
Households of
children with
Medium: small sample
Padmamohan Cross-sectional Intellectual disabilities were Treatment
India (Kerala) SA Low-middle Rural Population 98 (100%) Children 87 - size; unclear measure
et al. (2009) [26] study impairment identified by received
of disability
community health
workers
Met need
Intellectual
Ethiopia for
Dejene et al. Low Cross-sectional disability, autism
(Addis SSA Urban Clinic 102 (100%) Children Clinical diagnosis treatment 73 * - Low
(2016) [56] income study spectrum
Ababa) by health
disorder
professional
Table 4. Cont.
Results of studies measuring epilepsy
Zimbabwe
(Uzumba Self-report
Receipt of
Allain et al. Maramba Low Cross-sectional Older (bespoke tool, Medium: unclear
SSA Both Population 278 (NS) Epilepsy anti-epileptic 0 -
(1997) [16] Pfungwe, income study adults method unclear), measure of disability
medication
Bindura, nurse observation
Marondera)
Screening Ever sought
questionnaire biomedical
Coleman et al. Gambia Low Cross-sectional All
SSA Rural Population 69 (100%) Epilepsy followed by treatment 52 - Low
(2002) [57] (Farafenni) income study ages
psychologist for epilepsy
review (medication)
Key
Bangladesh informant
Nesbitt et al. Low Took up
(Natore, SA Both method; Population 1308 (100%) Children Epilepsy Clinical diagnosis - 34 Low
(2012) [24] income referral
Sirajgani) prospective
cohort study
* Met need calculated as 100-unmet need (27.5% unmet need for treatment by health professional). SSA: sub-Saharan Africa, LA: Latin America, SA: South Asia, EAP: East Asia & Pacific,
ME: Middle East; EU: Europe.
3.5.3. Access to Rehabilitation for Physical Impairment

Table 5 provides the results of 24 studies measuring access to rehabilitation for physical
impairment. Studies were conducted across 17 countries and five World Bank regions. Types of
physical impairments were varied, including rheumatoid or other arthritis (five studies), cerebral palsy
(two studies), leprosy (two studies), difficulties walking (six studies), amputation (one study),
musculoskeletal impairment (three studies), and unspecified physical impairment (eight studies).
In terms of method of assessment, four used the Washington Group short or extended set questions
(self-reported difficulties walking), eight used other self-reported tools, one used a chronic disorders
checklist, five used a clinical diagnosis, four selected participants from a registry, one used community
health worker report, and one study the method was unclear. Five studies were conducted among
adults, 11 among people of all ages, six among children and in two studies the age group was not
presented. Outcomes included access to physical therapy, assistive devices, medical rehabilitation,
and adherence. The vast majority of studies were conducted on population-based samples; however,
six sampled from clinic/hospital, and two from registries.
Access results for arthritis varied, with the highest coverage seen in Jordan (subnational) (76%)
and lowest in India (subnational) (4%). Adherence to leprosy treatment was also quite high (71–75%
in Nepal and Chad, both subnational studies); however, this may reflect the fact that these were
both clinic-based studies. Results were more varied for less specific physical impairments such
as “difficulties walking”, musculoskeletal impairment, and physical impairment—with coverage
of assistive devices ranging between 5–57% in Tanzania (subnational) and 41–93% in Cameroon
(subnational) (depending on the type of assistive device). Coverage of medical rehabilitation in Brazil
was 18%, while in South Africa this was 66%.
Coverage did not tend to increase with country income group or show a clear pattern by age
or locality across studies. El Sayed et al. (2015) found higher coverage among those covered with
insurance in a multi-country study [36].
Ten studies were judged to have low risk of bias. A further 14 studies were judged to have medium
(ten studies) or high risk of bias (four studies) due to unclear or unreliable measure of disability or
access (eight studies) or small sample size (four studies), or low response rate (three studies).
Table 5. Results for physical impairment.
Country World Proportion Covered by Type of

Study Author, Country Locality Participant Specific Method of
(Study Age Group Study Type N (%D) Outcome Rehabilitation % Risk of Bias
Year Bank Income (Urban/Rural) Source Condition Assessment
Location) Region Medical Assistive
Adherence
Rehabilitation Device
Coverage:
Bernabe-Ortiz Difficulties Washington Walking stick;
Peru Case control 798, 308 26; 33; 26; Medium: low
et al. (2016) LA Upper-middle Semi-urban All ages Population walking Group wheelchair, - -
(Moroppan) study (5%) 10 response rate
[17] (WG) short set crutches,
standing frame
Haiti
(Port-de-Paix,
Registry,
Cap-Haitien, Registry, Had a prosthetic
Bigelow et al. Low Cross-sectional 164 hospitals, High: small
Fort Liberte, LA Both All ages hospitals, Amputation limb in the past, - 25 -
(2004) [58] income study (100%) word of sample size
Port-au-Prince, organizations or currently had
mouth
Jacmel, Les
Cayes, Jeremie)
Proportion of
Physical
Devendra et al. Malawi Low Case control 592 WHO ten children who
SSA Unclear Children Clinic impairment 42 Low
(2013) [19] (Lilongwe) income study (50%) questions attended
(unspecified)
physiotherapy
Medium:
Self-report Care sought for
Doocy et al. Jordan Not Cross-sectional 9580 unreliable
ME Upper-middle Both Population Arthritis (bespoke chronic 76 - -
(2016) [59] (National) presented study (14%) measure of
tool) condition
disability
Self-report
El Sayed et al. 48 LMIC Cross-sectional 197,914 Proportion in
Various Various Both Adults Population Arthritis (bespoke 77 - - Low
(2015) [36] (National) study (NS) treatment
tool)
Ever received
Difficulties Self-report assistive devices;
Eide et al. Zambia Low Cross-sectional 2865
SSA Both All ages Population walking (bespoke Ever received 25 50 - Low
(2006) [44] (National) income study (100%)
(WG) tool) rehabilitation
(medical)
High: unclear
Patients
measure of
registered
Gadallah et al. Low-middle Cross-sectional 140 Arthritis Medication disability;
Egypt (Cairo) ME Urban Adults Clinic with - - 0
(2015) [60] income study (100%) (rheumatoid) adherence test clinic-based
rheumatology
sample; recall
clinic
bias likely
Medium:
Clinical unclear how
Kumar et al. Nepal Low Cross-sectional 273 examination Treatment patients
SA Unclear Adults Clinic Leprosy - - 71
(2004) [61] (Dhanusa) income study (42%) (WHO completion selected,
guidelines) clinic-based
sample
Coverage of:
Washington
Tanzania Difficulties Wheelchair;
Kuper et al. Low Case control 254 Group
(Mbeya, Tanga, SSA Both All ages Population walking crutches; - 5; 50; 53; 57 - Low
(2016) [20] income study (50%) short set +
Lindi) (WG) walking stick;
albinism
standing frame
Table 5. Cont.
Ever received
Difficulties Self-report assistive devices;
Loeb et al. Malawi Low Cross-sectional 1574
SSA Both All ages Population walking (bespoke Ever received 31 25 - Low
(2004) [43] (National) income study (100%)
(WG) tool) rehabilitation
(medical)
Physical Self-report Attendance at
Malta et al. Brazil Cross-sectional 204,000
LA Upper-middle Both All ages Population impairment (bespoke rehabilitation 18 - - Low
(2016) [23] (National) study (NS)
(unspecified) tool) services
Difficulties Washington Medical
Maart et al. South Africa Cross-sectional 151
SSA Upper-middle Urban All ages Population walking Group rehabilitation 66 - - Low
(2013) [21] (Cape Town) study (100%)
(WG) short set coverage
India Low-middle 845 Difficulties Washington Coverage of: 26; 43; 87;
Mactaggart et SA Case control
(Mahbabnagar) income Unclear All ages Population (60%) - 58 - Low
al. (2015) [22] study walking Group Wheelchair;
Cameroon (WG) extended crutches;
(Fundong Low-middle 703 set walking stick; 41; 32; 93;
SSA
Health income (61%) standing frame 33
District)
Attendance at
Bangladesh
McConachie et Low 47 Cerebral Clinical 8–9 distance Medium: small
(location SA Both Children Cohort study Clinic - 29
al. (2000) [62] income (100%) Palsy diagnosis training package sample size
unclear)
sessions
Bangladesh Physical
Nesbitt et al. Low Cross-sectional 1308 Clinical
(Natore, SA Both Children Population impairment Took up referral - - 50 Low
(2012) [24] income study (100%) assessment
Sirajgani) (unspecified)
Musculoskeletal Chronic
Ormel et al. Various Not Cross-sectional 73,441 Treatment
Various Various Both Population impairment disorders 52 - - Low
(2008) [49] (National) presented study (NS) prevalence
(MSI) checklist
Medium: small
Community
Padmamohan Physical sample size;
Low-middle Cross-sectional 98 health Treatment
et al. (2009) India (Kerala) SA Rural Children Population impairment 47 - - unclear
income study (100%) workers received
[26] (unspecified) measure of
assessment
disability
India (Assam,
Karnataka, Medium:
Raban et al. Maharashtra, Low-middle Retrospective 9994 Self-report Treatment unreliable
SA Both Adults Population Arthritis 58 - -
(2010) [37] Rajasthan, income study (NS) (validated) coverage measure of
Uttar Pradesh, disability
West Bengal)
Proportion who High: unclear
Range:
received response rate;
Saleh et al. Jordan Cross-sectional 116 Cerebral Clinical 24–100%
ME Upper-middle Both Children Clinic treatment for a - - small sample
(2015) [63] (Amman) study (100%) palsy diagnosis (median:
range of size; selection
50%)
problems bias
High: unclear
Footwear
measure of
Schafer et al. Chad (Guera Low Cross-sectional 351 Clinical coverage;
SSA Unclear All ages Clinic Leprosy - 45 73 access;
(1998) [64] prefecture) income study (48%) diagnosis treatment
potential for
completion rate
selection bias
Table 5. Cont.
Care sought
Medium:
Self-report from: qualified
Suman et al. India (West Low-middle Cross-sectional 43,999 unreliable
SA Both All ages Population Arthritis (bespoke provider 4; 3 - -
(2015) [65] Bengal) income study (1.3%) measure of
tool) (private),
disability
qualified (public)
Met need for:
Physical Mobility aid
Tan et al. (2015) Malaysia Cross-sectional 305 Medium: low
EAP Upper-middle Unclear Children Registry impairment Registry (e.g., 59 44 -
[28] (Penang) study (100%) response rate
(unspecified) wheelchair);
Physiotherapy
Proportion who
have access to
Thailand Medium:
Wanaratwichit Physical equipment;
(Phrae, Low-middle Cross-sectional 406 measure of
et al. (2008) EAP Unclear Adults Population impairment Unclear proportion who 67 55 -
Sukhothai, income study (100%) disability
[66] (unspecified) have access to
Chiang Rai) unclear
physical
rehabilitation
Medium:
China Received
unclear means
Zongjie et al. (Xincheng, Low-middle Cross-sectional Population, 460 Various rehabilitation in
EAP Unclear All ages Registry 27 - - of assessing
(2007) [67] Xuanwu, income study registry (100%) conditions the past 3
access and
Beijing) months
disability
SSA: sub-Saharan Africa, LA: Latin America, SA: South Asia, EAP: East Asia & Pacific, ME: Middle East; EU: Europe.
3.5.4. Access to Rehabilitation for Vision Impairment

In total, 17 studies measured access to rehabilitation for people with visual impairment across
13 countries in four World Bank regions. Table 6 outlines the results of these studies. The method of
assessment varied across studies with seven using self-reported tools (of these four used Washington
Group), seven using clinical examination, and three using other methods (registry, community leaders).
Thirteen studies measured medical rehabilitation, five studies measured access to assistive devices,
and one study measured uptake of referral. Medical rehabilitation for people with visual impairment
included consultation with specialist provider, and surgery uptake. All but two studies used a
population-based sample. Access to medical rehabilitation was varied, from 5% among people of all
ages in Brazil (national) to 82% among people of all ages in Nigeria (subnational). Similarly, results for
assistive device coverage were highly variable, but typically low.
Across studies, a clear pattern was not observed by country income group, age, or urban-rural
status. Higher coverage was identified for people with higher levels of education in several studies;
Kovai et al. (2007), Lee et al. (2013), Palyagi et al. (2008), but not all (Fletcher et al., 1999).
Considering the quality of studies in this category, 12 were judged as having low risk of bias.
The remaining five studies had high or medium risk of bias due to low or unclear response rate
(four studies), unclear measure of disability (two studies), or unclear measure of access (one study).
3.5.5. Access to Rehabilitation for Any Disability

Table 8 provides the results of 28 studies measuring access to rehabilitation for any disability
(i.e., those studies that did not disaggregate by impairment type, or reported overall coverage results).
These studies were conducted in 23 countries in six regions: the majority in sub-Saharan Africa
(12 studies). Outcomes included access to assistive devices (18 studies), general rehabilitation
(22 studies), and adherence (one study). Most studies sampled participants from the population,
with one each using clinic or registry as a sampling frame. 21 studies measured disability using
self-reported tools, including 12 using the Washington Group questions, two using the Rapid
Assessment of Disability tool, and the remainder used bespoke tools. Four studies used a clinical
examination. Two studies used registries to identify participants.
Coverage of general rehabilitation varied across studies. Coverage was particularly low in India
(subnational) and Bangladesh (subnational) at 5% and 7% respectively. In contrast studies in the
Philippines, South Africa, Malaysia, and Brazil (all subnational studies) found higher coverage at 70%,
71%, 76%, and 80%. Substantial variation was also found for access to assistive devices, but generally
coverage was low.
There did not appear to be a trend in coverage by country income group. The vast majority of these
studies were conducted in both urban and rural areas and did not disaggregate results, thus examining
patterns by locality was not possible. Furthermore, most studies were conducted among people of all
ages, with no disaggregation of results by age group. Within studies, four studies examined coverage
outcomes by indicators of equity. Three studies found lower coverage among females (Hosain et al.
(1998), Eide et al. (2006), Eide et al. (2009)), but no consistent patterns by age, socioeconomic status or
location were revealed.
Considering the strength of evidence for access to any specialist services, eight studies were
judged to have high or medium risk of bias, while the remaining were assessed as having low risk.
The main risks were—unclear or unreliable measure of disability (five studies), or low or unclear
response rate (five studies).
Table 6. Results of vision specific services.

Proportion Covered by Type of
World Country Rehabilitation %
Study Author, Type of Participant N Method of
Country Bank Income Locality Age Outcome Risk of Bias
Year Study Source (D%) Assessment Medical Assistive
Region Group Adherence
Rehabilitation Device
Visual acuity Ever sought
assessment; treatment (blind;
Ahmad et al. Pakistan Low-middle Cross-sectional 638
SA Unclear Older adults Population self-reported moderate visual 63; 50; 40 - - Low
(2015) [68] (Karachi) income study (24%)
eye/vision impairment; severe
problem visual impairment)
Bernabe-Ortiz Peru Cross-sectional 798,308 Washington Coverage: Medium: low response
LA Upper-middle Semi-urban All ages Population - 33 -
et al. (2016) (Morropon) study (5%) Group short set Magnifying glasses rate
Visual acuity Consulted a
Brian et al. Cross-sectional 1381
Fiji (National) EAP Upper-middle Both Older adults Population assessment and provider (blind; 62; 53 - - Low
(2012) [69] study (93%)
self-report low vision)
Proportion of
Devendra et al. Malawi Case control 592 WHO ten children who
SSA Low income Unclear Children Clinic 57 - - Low
(2013) [19] (Lilongwe) study (50%) questions attended eye clinic
of those in need
Attendance at
Fletcher et al. India Cross-sectional 1039 Visual acuity camps for people
SA Low income Rural Adults Population 7 - - Low
(1999) [70] (Maduari) study (34%) assessment identified as having
need
India
Kovai et al. Low-middle Cross-sectional 5573 Visual acuity
(Andhra SA Rural Adults Population Sought treatment 31 - - Low
Pradesh)
Tanzania
Kuper et al. Case control 254 Washington Coverage of: White
(Mbeya, SSA Low income Both All ages Population - 18; 50 - Low
(2016) [20] study (50%) Group short set cane; guide
Tanga, Lindi)
Consulted care
provider about
vision problem:
Lee et al. (2013) Timor Leste Low-middle Cross-sectional 2014 Visual acuity
EAP Both Older adults Population low 25;26 - - Low
[72] (12 districts) income study (93%) assessment
vision/blindness;
self-reported
problem
Proportion needing
Maart et al. South Africa Cross-sectional 151 Washington medical
SSA Upper-middle Urban All ages Population 57 - - Low
(2013) [21] (Cape Town) study (100%) Group short set rehabilitation that
received
Cameroon
(Fundong Low-middle 703 Washington Coverage of:
Mactaggart et SSA Case control - 15; 33 - Low
Health income Unclear All ages Population (61%)
al. (2015) [22] study Group extended Magnifying glasses;
District) set white cane
India Low-middle 845
SA - 46; 0 - Low
(Mahbabnagar) income (60%)
Trichiasis surgery Medium: small sample
Mahande et al. Tanzania Cohort 163 Visual acuity
SSA Low income Rural Older adults Population uptake (visual 47; 41 - - size, response rate
(2007) [73] (Hai) study (56%) assessment
impairment; blind) unclear
Table 6. Cont.
Attendance at
Malta et al. Brazil Cross-sectional 204,000 Self-report
LA Upper-middle Both All ages Population rehabilitation 5 - - Low
(2016) [23] (National) study (NS) (bespoke tool)
services
Key
informant
method
Bangladesh
Nesbitt et al. initially; 1308 Clinical
(Natore, SA Low income Both Children Population Took up referral - - 31 Low
(2012) [24] then (100%) examination
Sirajgani)
prospective
cohort
study
Timor Leste Sought treatment
Palagyi et al. Low-middle Cross-sectional 1414 Visual acuity
(Dili, EAP Both Older adults Population from Western Style 29 - - Low
Bobonaro) health services
India (Assam,
Karnataka,
Raban et al. Maharashtra, Low-middle Retrospective 9994 Self-report Medium: unreliable
SA Both Adults Population Treatment coverage 21 - -
(2010) [37] Rajasthan, income study (NS) (validated) measure of disability
Uttar Pradesh,
West Bengal)
Met need for: Medium: low response
Tan et al. (2015) Malaysia Cross-sectional 305
EAP Upper-middle Unclear Children Registry Registry Vision aids; Vision 52 47 - rate; unclear means of
[28] (Penang) study (100%)
related services assessing disability
Recruited
Previous eye check; High: unclear response
Udeh et al. Nigeria Cross-sectional 153 through
SSA Low income Unclear All ages Population Used low vision 82 0 - rate; unclear measure
(2014) [75] (Enugu state) study (100%) community
device of access
leaders
Table 7. Access to any rehabilitation.
World Country Means of Proportion Covered by Type of

Study Author, Type of Participant Sample
Country Income Locality Age Outcome Rehabilitation (%) Risk of Bias
Year Bank Study Source Size Assessing
Region Group Disability General Assistive
Adherence
Rehab Device
Any access to a range
Bernabe-Ortiz Peru Cross-sectional 798,608 Washington
LA Upper-middle Urban All ages Population of rehabilitation 11 Low
et al. (2016) [17] (National) study (5%) Group short set
services
Cross-sectional
Proportion using
Bernabe-Ortiz Peru study (with 3684 Washington Medium: low response
LA Upper-middle Semi-urban All ages Population rehabilitation now 5
et al. (2016) [76] (Morropon) nested case (8%) Group short set rate
among those in need
control)
936 Bespoke High: unclear measure
Borker et al. Low-middle Not Cross-sectional Use of rehabilitation
India (Goa) SA Rural Population families tool/clinical 24 of disability, no
(2012) [77] income presented study care
(18%) examination response rate reported
Met need for specialist
Danquah et al. Haiti Case control 376 Washington health care; medical
LA Low income Urban All ages Population 32; 49; 23 18 Low
(2015) [18] (Port-au-Prince) study (50%) Group short set rehabilitation;
specialist advice
Access to:
Devendra et al. Malawi Case control 592 WHO ten
SSA Low income Unclear Children Clinic rehabilitation services, 33 5 Low
(2013) [19] (Lilongwe) study (50%) questions
assistive devices
Eide et al. Zimbabwe Cross-sectional 1972 Self-report Received rehabilitation;
SSA Low income Both All ages Population 55 36 Low
(2003) [78] (National) study (100%) (bespoke tool) assistive devices
Loeb et al. Malawi Cross-sectional 1574 Self-report Received rehabilitation;
Eide et al. Namibia Cross-sectional 2528 Self-report Received rehabilitation;
SSA Low-middle Both All ages Population 26 17 Low
Eide et al. Zambia Cross-sectional 2865 Washington Received rehabilitation;
(2006) [44] (National) study (100%) Group short set assistive devices
Eide et al. Mozambique Cross-sectional 666 Washington Received rehabilitation;
Eide et al. Swaziland Cross-sectional 866 Washington Received rehabilitation;
SSA Low-middle Both All ages Population 31 32 Low
Eide et al. Nepal Cross-sectional 2123 Washington Received rehabilitation;
SA Low income Both All ages Population 22 22 Low
Eide et al. Botswana Cross-sectional 2123 Washington Received rehabilitation;
SSA Upper-middle Both All ages Population 33 34 Low
Palestine
Hamdan et at. Cross-sectional 806 Clinical
(Tulkarm, ME Low-middle Rural All ages Population Use of equipment 19 Low
(2009) [84] study (100%) examination
Qualqilia)
Bangladesh
Hosain et al. (Maniramore Cross-sectional 1906 Head of Sought treatment from Medium: unreliable
SA Low income Rural All ages Population 34
(1998) [85] Thana, Jessore study (8%) household report qualified provider measure of disability
district)
High: unreliable
Kisioglu et al. Turkey Cross-sectional 3500 Self-report Receipt of
EU Low-middle Both All ages Population 5 measure of disability;
(2003) [86] (Isparta) study (5%) (bespoke tool) rehabilitation
unclear response rate
Table 8. Access to any rehabilitation.

Kuper et al. Kenya Case control 807 Washington Receipt of
SSA Low income Unclear Children Population 15 Low
(2015) [87] (Turkana) study (39%) Group short set rehabilitation
Coverage of
Tanzania rehabilitation services;
Kuper et al. Case control 254 Washington
(Mbeya, SSA Low income Both All ages Population specialist health 20; 5 33 Low
(2016) [20] study (50%) Group short set
Tanga, Lindi) services; assistive
devices
Maart et al. South Africa Cross-sectional 151 Washington Medical rehabilitation;
SSA Upper-middle Urban All ages Population 71 66 Low
(2013) [21] (Cape Town) study (100%) Group short set assistive device
India Low-middle 703 Washington Met need for medical
Mactaggart et SA Case control 61 48
(Mahbabnagar) income Unclear All ages Population (61%) Low
al. (2015) [22] study Group extended rehabilitation; assistive
Cameroon set devices
(Fundong Low-middle 845
SSA 76 44
Health income (60%)
District)
Fiji (not 101 Rapid Access to rehabilitation;
Marella et al. EAP Upper-middle Case control 45 35
specified) Both Adults Population (50%) Low
(2014) [88] study Assessment of access to assistive
Bangladesh 195 Disability devices
SA Low income 7 12
(Bogra) (50%)
Philippines Rapid Access to rehabilitation;
Marella et al. Low-middle Case control 204,000
(Quezon, EAP Both Adults Population Assessment of Access to assistive 70 46 Low
(2016) [89] income study (6%)
Liago City) Disability devices
Bangladesh Prospective
Nesbitt et al. 1308 Clinical
(Natore, SA Low income Both Adults cohort Population Uptake of referral 48 Low
(2012) [24] (100%) examination
Sirajgani) study
Thailand
(Non Bon, 99 Assistive device
Nualnetr et al. Low-middle Not Cross-sectional
Kosum Phisai, EAP Rural Registry (99; Not specified received and 33 - Low
(2012) [90] income specified study
Maha 100%) appropriate
Sarakham)
Medium: small sample
Community
Padmamohan Low-middle Cross-sectional 98 Use of rehabilitation size, method of
India (Kerala) SA Rural Children Population health workers 48
et al. (2009) [26] income study (100%) treatment disability assessment
assessment
unreliable
Bespoke
Medium: unclear
Pongprapai et Thailand Cross-sectional 53 questionnaire and Sought treatment for
EAP Low-middle Unclear Children Population 62 measure of disability;
al. (1996) [91] (Nongjik) study (100%) clinical child’s condition
unclear response rate
examination
Souza et al. Cross-sectional 235 Self-report Ever received Medium: unclear
Brazil (Bahia) LA Upper-middle Urban All ages Population 80
(2012) [92] study (100%) (bespoke tool) treatment measure of disability
Met need for services
Tan et al. (2015) Malaysia Cross-sectional 305 (specialist doctor; Medium: low response
EAP Upper-middle Unclear Children Registry Registry 76
[28] (Penang) study (100%) therapy; assistive rate
device)
3.5.6. Barriers
Of the 77 included studies, 22 evaluated barriers to accessing rehabilitation as secondary outcomes.
Commonly reported barriers included logistical factors (distance to service, lack or cost of transport),
affordability (of services, treatment, lack of insurance), and knowledge and attitudinal factors
(including perceived need, fear, and lack of awareness about the service) (Table 9). Many of these
barriers identified are not unique to disability. However, particular barriers were disability-related,
including discrimination from the health provider, provider lacking skills, and communication barriers,
or potentially enhanced among people with disabilities (e.g., lack of affordability).
Table 9. Barriers to accessing rehabilitation reported across studies.
Barrier Reference
Geographic accessibility
Distance to service [19,21,26,28,31,47,69,71,72,74,93]
Transport problems [18,19,21,28,31,69,72,74,77,84,89,94]
Nobody to accompany [28,69,71,72,74,77,93]
Affordability
Unable to afford services [18–22,26,27,31,47,58,62,67,71,72,74,77,84,89]
Unable to afford treatment [19,47,60,70,75,93]
No insurance [47]
Acceptability
Do not know where to go for treatment [27,28,31,47,48,69,71,72,74,93]
Have not heard about service [75]
Thought nothing could be done [31,48,69–72,74]
Lack of perceived need [20,31,47,48,69–72,74,95]
Family do not perceive need [71]
Fear of seeking care [31,69–72,74]
No time/other priorities [28,47,69–72,74,84,93]
Other medical problems [60,71]
Shame [31,95]
Lack of trust in healthcare providers keeping confidentiality [31]
Availability
Waiting time at the clinic [31,74,77]
Not availability of drugs, services [21,28,60,75,84,93]
Quality
Discrimination/poor treatment from health provider [19,21,28,31,47,69]
Poor relationship with provider [70,71,95]
Provider refused care [28,84]
Communication barrier [21]
Provider lacks skills [28,67]
4. Discussion
4.1. Review of Findings

This systematic review summarises the available evidence on access to rehabilitation services
for hearing (13 studies), visual (17 studies), physical (24 studies) mental (34 studies), and any
disability-related service (27 studies). The review captured studies a wide range of World Bank
geographic regions, and over 60 countries.
Access results were varied across studies. Access to hearing specific services ranged from 0
to 66%. For visual impairment this was 0 to 82%, physical 0 to 93%, mental 0 to 97% and any
disability-related services was 5 to 80%. Despite the variation, overall, access was low; however, there
were some outlier studies showing high coverage. The review highlighted that outcomes used to
measure access to rehabilitation, as well as measures of impairment/disability, are varied making

comparisons and generalizability difficult. Coverage of services where disability is measured using
self-reported tools such as the Washington Group short set of functioning, assumes that people who
report difficulties are in need of rehabilitation. This may not be the most accurate measure of coverage
(e.g., people blind from cataract may require surgery, not low vision aids) and further work is required
to develop standard methods of measurement. Most studies used population-based, cross-sectional
data, where the population in need in a particular region were identified (i.e., a prevalence study) and
asked about access to services. However, we included studies where participants were sampled from
clinics, or registries. These studies are very likely to overestimate coverage given these individuals
have already been in touch with some type of service.
In terms of barriers to accessing rehabilitation, common themes across 22 studies in a diverse
range of settings included lack of affordability of services, equipment, or medication as reasons for
not accessing care. In addition, logistical or geographical factors such as distance to the service,
transportation problems, and a lack of a chaperone. Several service-related barriers including
discrimination from provider, communication barriers, and lack of provider skill were also common.
These barriers may be specific to or greater for people with disabilities than those without disabilities.
Further research is needed to examine particular barriers to access that people with disabilities face in
greater depth.
The quality of included studies was generally high. There was limited evidence to support
an association of coverage with country income group, age, urban-rural location, or other variables
such as socioeconomic status. Included studies did not routinely disaggregate results by these
variables—with less than a third of studies measuring variables related to equity of coverage.
4.2. Consistency with Previous Reviews

To our knowledge, this is the first systematic review that has attempted to summarize the available
evidence on access to health-related rehabilitation for people with disabilities in LMIC. Thus, there are
few similar examples from the literature to which the results can be compared.
Several previous reviews have focused on coverage of mental health services, evidence on assistive
device coverage, and rehabilitation workforce literature. In a recent scoping review by Matter et al.
(2017), authors identified a lack of publications on assistive devices from LMIC, in particular with
respect to data on hearing, communication or cognition [96]. Similarly, a previous review by De Silva
et al. (2014) on coverage of mental health programs highlighted that there was limited evidence on the
topic [97]. They noted coverage estimations varied across studies, making comparisons difficult and
called for coverage estimates to be stratified by age, gender, socioeconomic status to understand equity
of coverage. These conclusions align with the findings of our review.
Jesus et al. (2017) conducted a review of rehabilitation workforce literature [98]. They found that
substantial shortages of rehabilitation workers are documented in low income countries, particularly
in sub-Saharan Africa and Latin America—with only six physicians specialized in rehabilitation in
sub-Saharan Africa. Few programs exist for obtaining a qualification in rehabilitation, with several
studies reporting alternative health worker cadres which could mitigate this; however, there is limited
evidence on effectiveness. Although these findings have a health systems perspective on access to
health services, they help to explain the reported low coverage of rehabilitation services in many studies
in our review. Bruckner et al. (2010) also found that out of 58 LMIC involved in the WHO Assessment
Instrument for Mental Health Systems surveys, that the vast majority did not meet expected health
workforce targets for delivery of mental health services [99].
Several national surveys have been conducted in high-income countries such as the United
Kingdom, the United States, and Korea. In the United States, a nationwide survey of people with
cerebral palsy, multiple sclerosis, and spinal cord injury found that nearly one third of those who
indicated a need did not receive assistive equipment every time it was needed. Over half of people
had an unmet need for rehabilitative services [100]. In Korea, a 2009 nationally representative study
(Korean National Health and Nutrition Examination Survey—KHANES) found that less than 10% of
people with depressive mood had used mental health services [101]. In the United Kingdom, analysis
of the European Health Interview Survey found that people with severe disability had higher odds of
facing unmet need for health care, with the largest gap for mental health care [102]. Although these
studies show high unmet need for services also exists in high-income contexts, access to rehabilitation
is likely to be much poorer in LMIC.
The WHO have commonly cited statistics on coverage of assistive devices. For instance, it is
estimated that hearing aid production meets less than 10% of the global need and less than 3% of
people who need hearing aids in LMIC actually receive them. Furthermore, previous WHO estimates
suggests that in many LMIC, 5–15% of people with disabilities have access to assistive devices [6].
Our review found wide variation in coverage of hearing aids and assistive devices but does agree
that coverage is generally low. Again, the range of measurements of both disability and access limit
comparability across studies.
4.3. Implications for Practice

This review has shown that in general, access to rehabilitation services is low in many LMIC.
However, evidence is lacking from many countries of the world. To enable full implementation of
the UNCRPD, member states must ensure that rehabilitation services are accessible to people with
disabilities. Despite the UNCRPD providing a clear legal and regulatory framework, this review
alongside key publications from the WHO, suggests that people with disabilities are not receiving a
range of specific health services required to improve functioning. Evidence suggests that per capita
income is linked to the level of implementation of the UNCRPD—underlining the major challenge
for LMIC [103]. As outlined in the call to action in Rehabilitation 2030 there is an urgent need to
address the unmet need for these services [5]. Although we have specifically focused on people with
disabilities, rehabilitation has a broader scope, with some people needing rehabilitation temporarily at
certain points in life (e.g., after a sports injury). Thus, addressing rehabilitation needs for people with
disabilities has a wider benefit. Increasing life expectancy means the needs for rehabilitation will also
increase, reinforcing the need to address this gap.
Rehabilitation should be integrated in to health systems at all levels to maximize access and
achieve UHC. Rehabilitation in Health Systems guidance from the WHO provides recommendations for
member states to strengthen and expand the availability of quality rehabilitation [104]. These, and other
initiatives, include supply-side interventions, which attempt to address the dearth of services available
to provide rehabilitation in LMIC. For instance, the GATE program of the WHO aims to improve
access to affordable devices globally through various mechanisms [11]. Community-based models of
health care delivery have been attempted for specific health services including: mental health, eye care,
and ear and hearing care. These task shifting approaches are endorsed by the WHO as a mechanism to
overcome skills shortages and reach underserved populations [105]. Telemedicine is a growing area
for provision of rehabilitation and may help overcome the geographical barriers commonly reported
in the literature. As an example, in the field of hearing impairment, telemedicine has been used for
screening, diagnosis, and hearing aid fittings [106]. Furthermore, mobile technology has huge potential
for improving access to rehabilitation. For example, in Kenya smartphone-based assistive technologies
have been tested for students with visual impairment with positive impact on access to education,
and participation in everyday life [107]. Sureshkumar et al. (2015) have tested a smartphone-based
educational intervention for people with physical impairments following stroke in India [108].
Furthermore, demand-side interventions such as financial incentives and health promotion/education
may help to improve uptake of available services. This includes strategies such as ensuring health insurance
covers rehabilitation services, which will help to avoid catastrophic health expenditure. Two systematic
reviews conducted by Bright et al. found that delivery of services at or close to home, text-message
reminders, and vouchers may be beneficial for improving access to services for children in LMIC,
but more evidence is needed on “what works” to improve access for people with disabilities [109,110].
4.4. Implications for Research
Use Common Definitions of Disability and Coverage

To monitor progress towards the SDGs with respect to disability, and for program-planning
purposes, key indicators of access to and coverage of rehabilitation should be developed, with a
uniform method of measurement to allow comparability. This includes using clear definitions of what
is meant by rehabilitation (e.g., medical rehabilitation, assistive technology, and therapy) and how
coverage or access are measured. Access to health-related rehabilitation in this review was usually
measured in terms of “coverage”, that is the proportion of people needing a service who reported
receiving it. However, this may overestimate coverage as the service may be inadequate and/or the
full course of treatment may not be completed. Better measures of “access” are therefore needed.
Furthermore, common definitions of disability should be adopted. Ideally, this should focus on clinical
measurement of impairment, as these will also provide further information about the rehabilitation
needs [111]. For instance, self-reported hearing difficulties does not give adequate information about
service needs, which may range from basic wax removal to more complex surgeries or hearing aid
fitting. Clinical assessment would provide the information needed to plan rehabilitation and specialist
services. In addition, equity of service coverage should be assessed as part of any data collection to
monitor access to rehabilitation. Sociodemographic information such as age, gender, socioeconomic
status, locality, should be collected which can then allow data disaggregation. Monitoring the
effectiveness and quality of rehabilitation care received is crucial for informing service delivery
improvements, and ensuring functioning is maximized for people with disabilities.
4.5. Limitations and Strengths

This review has several limitations that need to be taken in to account. We focused on literature
from peer-reviewed sources, and it is possible that some relevant data is available in grey literature
sources, not captured in our search. Although we placed no restrictions on language, the electronic
searches were conducted on six databases in the English language, and thus some literature may have
been missed. Although our review encompassed a broad range of countries, and all the World Bank
regions except for North America (high income), a third of studies came from sub-Saharan Africa.
Our results may be slightly biased towards the conditions in these countries. However, the range of
countries in sub-Saharan Africa included were limited to 15 of the 48 countries—suggesting that despite
the largest proportion of data coming from this region, further research is required. Data was lacking
from many parts of the world, with only 16% of included studies from Latin American countries,
therefore included studies may not be representative of the level of access to rehabilitation in many
LMICs. Studies may have been conducted in countries where stronger rehabilitation services exist,
which may exaggerate the results found. The vast majority of studies were conducted at district
level (73%), rather than national level, so making inferences about the situation of rehabilitation
access in a whole country is limited. In the analysis we compared results by country income level
(low, low-middle, and upper-middle). Ideally, a comparison between the results of studies by region
(e.g., LMICs in Africa) would have been made, however the range of measurement types used limits
comparability. Our review did not have a focus on the availability of services, which is an important
dimension of access and may help to explain poor coverage of rehabilitation [112]. The scope of our
review was on health-related rehabilitation and does not focus on broader needs such as education or
work-related rehabilitation. We also did not include access to sign language education, rather than
medical interventions for hearing impairment. Thus, we have not captured access to rehabilitation
in its broadest sense as defined in Rehabilitation 2030. This warrants further attention. We did not
assess the costs of accessing rehabilitation services, even though financial constraints were a major
reason for not seeking care. Finally, we did not place any restrictions on publication date in our review,
which means we have captured available literature to date; however, some studies may be outdated,
and not reflective of the current level of access in the country studied.
There are also several strengths. This review was large, and adopted a systematic approach,
following Cochrane guidelines. We used a comprehensive list of search terms to capture the literature
available on this topic. It captured a broad range of disability types, and across a diverse range of
countries and published in different languages.
5. Conclusions
This systematic review on access to rehabilitation for people with disabilities found wide variation
in reported coverage across studies. In general, coverage appeared to be low for medical rehabilitation,
assistive devices, therapy, and adherence. However, the review has identified a need to develop
standard indicators for measuring coverage of rehabilitation to allow comparability. There is also
a need to use comparable measures of disability. Common measures will contribute towards a greater
understanding of the met and unmet needs for rehabilitation for people with disabilities and allow
planning of appropriate services.
Supplementary Materials: The following are available online at http://www.mdpi.com/1660-4601/15/10/2165/

s1, Table S1: EMBASE search strategy.
Author Contributions: Conceptualization, T.B. and H.K.; Methodology, T.B. and H.K.; Formal Analysis, T.B.; Data
Curation, T.B., S.W. and H.K.; Writing-Original Draft Preparation, T.B.; Writing-Review & Editing, T.B., S.W. and
H.K.; Funding Acquisition, H.K.
Funding: This research was funded by CBM International grant number ITCRZK1810. The funders had no role in
the design of the study, data extraction, analysis, interpretation or writing of the report.
Acknowledgments: The authors are grateful to Cova Bascaran for her assistance with data extraction for
Spanish articles.
Conflicts of Interest: The authors declare no conflict of interest.
References
1. World Bank; World Health Organization. The World Report on Disability. Available online: http://www.
who.int/disabilities/world_report/2011/en/ (accessed on 13 April 2018).
2. World Health Organization. Towards a Common Language for Functioning, Disability and Health; World Health
Organization: Geneva, Switzerland, 2002.
3. Prince, M.; Patel, V.; Saxena, S.; Maj, M.; Maselko, J.; Phillips, M.R.; Rahman, A. No health without mental
health. Lancet 2007, 370, 859–877. [CrossRef]
4. Banks, L.M.; Kuper, H.; Polack, S. Poverty and disability in low- and middle-income countries: A systematic
review. PLoS ONE 2017, 12, e0189996. [CrossRef] [PubMed]
5. World Health Organization. Rehabilitation 2030: A Call for Action. 2017. Available online: http://www.
who.int/disabilities/care/rehab-2030/en/ (accessed on 24 April 2018).
6. World Health Organization. Assistive Devices/Technologies: What WHO Is Doing. Available online:
http://www.who.int/disabilities/technology/activities/en/ (accessed on 18 July 2018).
7. World Health Organization. Guidelines for Hearing Aids and Services for Developing Countries; World Health
Organization: Geneva, Switzerland, 2004.
8. World Health Organization. Universal Health Coverage and Health Financing. 2018. Available online:
http://www.who.int/health_financing/universal_coverage_definition/en/ (accessed on 13 April 2018).
9. United Nations. Sustainable Development Goals. Available online: https://sustainabledevelopment.un.
org/?menu=1300 (accessed on 18 July 2018).
10. United Nations. Convention on the Rights of Persons with Disabilities—Articles. 2006. Available
online: https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-
disabilities/convention-on-the-rights-of-persons-with-disabilities-2.html (accessed on 28 September 2018).
11. World Health Organization. Global Cooperation on Assistive Technologies (GATE). 2014. Available online:
http://www.who.int/phi/implementation/assistive_technology/phi_gate/en/ (accessed on 13 April 2018).
12. Ramke, J.; Gilbert, C.E.; Lee, A.C.; Ackland, P.; Limburg, H.; Foster, A. Effective cataract surgical coverage: An
indicator for measuring quality-of-care in the context of Universal Health Coverage. PLoS ONE 2017, 12, e0172342.
[CrossRef] [PubMed]
13. Fricke, T.R.; Tahhan, N.; Resnikoff, S.; Papas, E.; Burnett, A.; Ho, S.M.; Naduvilath, T.; Naidoo, K.S.
Global Prevalence of Presbyopia and Vision Impairment from Uncorrected Presbyopia: Systematic Review,
Meta-analysis, and Modelling. Ophthalmology 2018, 125, 1492–1499. [CrossRef] [PubMed]
14. IAPB. Spectacle Coverage Report. 2017. Available online: https://www.iapb.org/resources/spectacle-
coverage-report/ (accessed on 18 July 2018).
15. Scottish Intercollegiate Guidelines Network. SIGN 50: A Guideline Development Handbook. 2011. Available
online: http://www.sign.ac.uk/assets/sign50_2011.pdf (accessed on 13 April 2018).
16. Allain, T.J.; Wilson, A.O.; Gomo, Z.A.R.; Mushangi, E.; Senzanje, B.; Adamchak, D.J.; Matenga, J.A. Morbidity
and disability in elderly Zimbabweans. Age Ageing 1997, 26, 115–121. [CrossRef] [PubMed]
17. Bernabe-Ortiz, A.; Diez-Canseco, F.; Vásquez, A.; Miranda, J.J. Disability, caregiver’s dependency and
patterns of access to rehabilitation care: Results from a national representative study in Peru. Disabil. Rehabil.
2016, 38, 582–588. [CrossRef] [PubMed]
18. Danquah, L.; Polack, S.; Brus, A.; Mactaggart, I.; Houdon, C.P.; Senia, P.; Gallien, P.; Kuper, H. Disability in
post-earthquake Haiti: Prevalence and inequality in access to services. Disabil. Rehabil. 2015, 37, 1082–1089.
[CrossRef] [PubMed]
19. Devendra, A.; Makawa, A.; Kazembe, P.N.; Calles, N.R.; Kuper, H. HIV and Childhood Disability: A
Case-Controlled Study at a Paediatric Antiretroviral Therapy Centre in Lilongwe, Malawi. PLoS ONE
2013, 8, e84024. [CrossRef] [PubMed]
20. Kuper, H.; Walsham, M.; Myamba, F.; Mesaki, S.; Mactaggart, I.; Banks, M.; Blanchet, K. Social protection for
people with disabilities in Tanzania: A mixed methods study. Oxf. Dev. Stud. 2016, 44, 441–457. [CrossRef]
21. Maart, S.; Jelsma, J. Disability and access to health care—A community based descriptive study. Disabil.
Rehabil. 2014, 36, 1489–1493. [CrossRef] [PubMed]
22. Mactaggart, I.; Kuper, H.; Murthy, G.V.S.; Sagar, J.; Oye, J.; Polack, S. Assessing health and rehabilitation
needs of people with disabilities in Cameroon and India. Disabil. Rehabil. 2016, 38, 1757–1764. [CrossRef]
[PubMed]
23. Malta, D.C.; Stopa, S.R.; Canuto, R.; Gomes, N.L.; Mendes, V.L.; Goulart, B.N.; Moura, L. Self-reported prevalence
of disability in Brazil, according to the National Health Survey, 2013. Cienc. Saude Colet. 2016, 21, 3253–3264.
[CrossRef] [PubMed]
24. Nesbitt, R.C.; Mackey, S.; Kuper, H.; Muhit, M.; Murthy, G.V. Predictors of referral uptake in children with
disabilities in Bangladesh—Exploring barriers as a first step to improving referral provision. Disabil. Rehabil.
2012, 34, 1089–1095. [CrossRef] [PubMed]
25. Omondi, D.; Ogol, C.; Otieno, S.; Macharia, I. Parental awareness of hearing impairment in their school-going
children and healthcare seeking behaviour in Kisumu district, Kenya. Int. J. Pediatr. Otorhinolaryngol.
2007, 71, 415–423. [CrossRef] [PubMed]
26. Padmamohan, J.; Nair, M.K.C.; Devi, S.R.; Nair, S.M.; Leena, M.L.; Kumar, G.S. Utilization of rehabilitation
services by rural households with disabled preschool children. Indian Pediatr. 2009, 46, S79–S82. [PubMed]
27. Ribas, A.; Guarinello, A.C.; Braga, M.; Cribari, J.; Filho, O.B.; Cardoso, S.M.S.; Martins, J. Access to hearing
health service in Curitiba-PR for the elderly with hearing loss and tinnitus. Int. Tinnitus J. 2015, 19, 59–63.
[CrossRef] [PubMed]
28. Tan, S.H. Unmet Health Care Service Needs of Children with Disabilities in Penang, Malaysia. Asia Pac. J
Public Health 2015, 27, 41S–51S. [CrossRef] [PubMed]
29. Abas, M.A.; Broadhead, J.C. Depression and anxiety among women in an urban setting in Zimbabwe.
Psychol. Med. 1997, 27, 59–71. [CrossRef] [PubMed]
30. Alekhya, P.; Sriharsha, M.; Venkata Ramudu, R.; Shivanandh, B.; Priya Darsini, T.; Reddy, K.S.K.; Hrushikesh
Reddy, Y. Adherence to antidepressant therapy: Sociodemographic factor wise distribution. Int. J. Pharm.
Clin. Res. 2015, 7, 180–184.
31. Andersson, L.M.C.; Schierenbeck, I.; Strumpher, J.; Krantz, G.; Topper, K.; Backman, G.; Ricks, E.;
Van Rooyen, D. Help-Seeking Behaviour, Barriers to Care and Experiences of Care among Persons with
Depression in Eastern Cape, South Africa. J. Affect. Disord. 2013, 151, 439–448. [CrossRef] [PubMed]
32. Hailemariam, S.; Tessema, F.; Asefa, M.; Tadesse, H.; Tenkolu, G. The prevalence of depression and associated
factors in Ethiopia: Findings from the National Health Survey. Int. J. Ment. Health Syst. 2012, 6, 23. [CrossRef]
[PubMed]
33. De Snyder, V.N.; de Jesús Díaz-Pérez, M. Los trastornos afectivos en la población rural. Salud Ment. 1999, 22, 68–74.
34. Karam, E.G. The nosological status of bereavement-related depressions. Br. J. Psychiatry 1994, 165, 48–52.
[CrossRef] [PubMed]
35. Fujii, R.K.; Goren, A.; Annunziata, K.; Mould-Quevedo, J. Prevalence, Awareness, Treatment, and Burden of
Major Depressive Disorder: Estimates from the National Health and Wellness Survey in Brazil. Value Health
Reg. Issues 2012, 1, 235–243. [CrossRef] [PubMed]
36. El-Sayed, A.M.; Palma, A.; Freedman, L.P.; Kruk, M.E. Does health insurance mitigate inequities in
non-communicable disease treatment? Evidence from 48 low- and middle-income countries. Health Policy
2015, 119, 1164–1175. [CrossRef] [PubMed]
37. Raban, M.Z.; Dandona, R.; Anil Kumar, G.; Dandona, L. Inequitable coverage of non-communicable diseases
and injury interventions in India. Natl. Med. J. India 2010, 23, 267–273. [PubMed]
38. Padmavathi, R.; Rajkumar, S.; Srinivasan, T.N. Schizophrenic patients who were never treated—A study in
an Indian urban community. Psychol. Med. 1998, 28, 1113–1117. [CrossRef] [PubMed]
39. Lora, A. Service availability and utilization and treatment gap for schizophrenic disorders: A survey in
50 low-and middle income countries. Eur. Arch. Psychiatry Clin. Neurosci. 2013, 263, S52. [CrossRef]
[PubMed]
40. Demyttenaere, K.; Bruffaerts, R.; Posada-Villa, J.; Gasquet, I.; Kovess, V.; Lepine, J.P.; Angermeyer, M.C.;
Bernert, S.; de Girolamo, G.; Morosini, P.; et al. Prevalence, severity, and unmet need for treatment of mental
disorders in the World Health Organization World Mental Health Surveys. JAMA 2004, 291, 2581–2590.
[PubMed]
41. Andrade, L.; Walters, E.W.; Gentil, V.; Laurenti, R. Prevalence of ICD-10 Mental Disorders in a Catchment
Area in the City of São Paulo, Brazil. Soc. Psychiatry Psychiatr. Epidemiol. 2002, 37, 316–325. [CrossRef]
[PubMed]
42. Caraveo-Anduaga, J.J.; Colmenares, B.; Saldívar, H.; Gabriela, J. Morbilidad psiquiátrica en la ciudad de
México: Prevalencia y comorbilidad a lo largo de la vida. Salud Ment. 1999, 22, 6.
43. Loeb, M.E.; Eide, A.H. Living Conditions among People with Activity Limitations in Malawi: A National
Representative Study; SINTEF: Trondheim, Norway, 2004.
44. Eide, A.H.; Loeb, M.E. Living Conditions among People with Activity Limitations in Zambia: A National
Representative Study; SINTEF: Trondheim, Norway, 2006.
45. Alhasnawi, S.; Sadik, S.; Rasheed, M.; Baban, A.; Al-Alak, M.M.; Othman, A.Y.; Othman, Y.; Ismet, N.;
Shawani, O.; Murthy, S.; et al. The prevalence and correlates of DSM-IV disorders in the Iraq Mental Health
Survey (IMHS). World Psychiatry 2009, 8, 97–109. [PubMed]
46. Li, N.; Du, W.; Chen, G.; Song, X.; Zheng, X. Mental Health Service Use among Chinese Adults with Mental
Disabilities: A National Survey. Psychiatr. Serv. 2013, 64, 638–644. [CrossRef] [PubMed]
47. Chikovani, I.; Makhashvili, N.; Gotsadze, G.; Patel, V.; McKee, M.; Uchaneishvili, M.; Rukhadze, N.;
Roberts, B. Health Service Utilization for Mental, Behavioural and Emotional Problems among
Conflict-Affected Population in Georgia: A Cross-Sectional Study. PLoS ONE 2015, 10, e0122673. [CrossRef]
[PubMed]
48. Trump, L.; Hugo, C. The barriers preventing effective treatment of South African patients with mental health
problems. Afr. J. Psychiatry 2006, 9, 249–260. [CrossRef]
49. Ormel, J.; Petukhova, M.; Chatterji, S.; Aguilar-Gaxiola, S.; Alonso, J.; Angermeyer, M.C.; Bromet, E.J.;
Burger, H.; Demyttenaere, K.; de Girolamo, G.; et al. Disability and treatment of specific mental and physical
disorders across the world. Br. J. Psychiatry 2008, 192, 368–375. [CrossRef] [PubMed]
50. Seedat, S.; Williams, D.R.; Herman, A.A.; Moomal, H.; Williams, S.L.; Jackson, P.B.; Myer, L.; Stein, D.J.
Mental health service use among South Africans for mood, anxiety and substance use disorders. S. Afr. Med.
J. 2009, 99, 346–352. [PubMed]
51. Ma, N.; Liu, J.; Wang, X.; Gan, Y.W.; Ma, H.; Ng, C.H.; Jia, F.J.; Yu, X. Treatment dropout of patients in
National Continuing Management and Intervention Program for Psychoses in Guangdong Province from
2006 to 2009: Implication for mental health service reform in China. Asia-Pac. Psychiatry 2012, 4, 181–188.
[CrossRef]
52. Caraveo-Anduaga, J.J.; Martínez Vélez, N.A.; Rivera Guevara, B.E.; Dayan, A.P. Prevalencia en la vida de
episodios depresivos y utilización de servicios especializados. Salud Ment. 1997, 20, 15–23.
53. Paula, C.S.; Bordin, I.A.S.; Mari, J.J.; Velasque, L.; Rohde, L.A.; Coutinho, E.S.F. The Mental Health Care
Gap among Children and Adolescents: Data from an Epidemiological Survey from Four Brazilian Regions.
PLoS ONE 2014, 9, e88241. [CrossRef] [PubMed]
54. Chadda, R.K.; Pradhan, S.C.; Bapna, J.S.; Singhal, R.; Singh, T.B. Chronic psychiatric patients: An assessment
of treatment and rehabilitation-related needs. Int. J. Rehabil. Res. 2000, 23, 55–58. [CrossRef] [PubMed]
55. Llosa, A.E.; Ghantous, Z.; Souza, R.; Forgione, F.; Bastin, P.; Jones, A.; Antierens, A.; Slavuckij, A.; Grais, R.F.
Mental disorders, disability and treatment gap in a protracted refugee setting. Br.J. Psychiatry 2014, 204, 208–213.
[CrossRef] [PubMed]
56. Dejene, T.; Hanlon, C.; Abebaw, F.; Tekola, B.; Yonas, B.; Hoekstra, R.A. Stigma, explanatory models and
unmet needs of caregivers of children with developmental disorders in a low-income African country: A
cross-sectional facility-based survey. BMC Health Serv. Res. 2016, 16, 152.
57. Coleman, R.; Loppy, L.; Walraven, G. The treatment gap and primary health care for people with epilepsy in
rural Gambia. Bull. World Health Organ. 2002, 80, 378–383. [PubMed]
58. Bigelow, J.; Korth, M.; Jacobs, J.; Anger, N.; Riddle, M.; Gifford, J. A picture of amputees and the prosthetic
situation in Haiti. Disabil. Rehabil. 2009, 26, 246–252. [CrossRef]
59. Doocy, S.; Lyles, E.; Akhu-Zaheya, L.; Oweis, A.; Al Ward, N.; Burton, A. Health Service Utilization among
Syrian Refugees with Chronic Health Conditions in Jordan. PLoS ONE 2016, 11, e0150088. [CrossRef]
[PubMed]
60. Gadallah, M.A.; Boulos, D.N.K.; Gebrel, A.; Dewedar, S.; Morisky, D.E. Assessment of Rheumatoid Arthritis
Patients’ Adherence to Treatment. Am. J. Med. Sci. 2015, 349, 151–156. [CrossRef] [PubMed]
61. Kumar, R.B.C.; Singhasivanon, P.; Sherchand, J.B.; Mahaisavariya, P.; Kaewkungwal, J.; Peerapakorn, S.;
Mahotarn, K. Gender differences in epidemiological factors associated with treatment completion status
of leprosy patients in the most hyperendemic district of Nepal. Southeast Asian J. Trop. Med. Public Health
2004, 35, 334–339. [PubMed]
62. McConachie, H.; Huq, S.; Munir, S.; Akhter, N.; Ferdous, S.; Khan, N.Z. Difficulties for mothers in using an
early intervention service for children with cerebral palsy in Bangladesh. Child 2001, 27, 1–12. [CrossRef]
63. Saleh, M.; Almasri, N.A. Cerebral palsy in Jordan: Demographics, medical characteristics, and access to
services. Child. Health Care 2017, 46, 49–65. [CrossRef]
64. Schafer, J. Leprosy and disability control in the Guera prefecture of Chad, Africa: Do women have access to
leprosy control services? Lepr. Rev. 1998, 69, 267–278. [CrossRef] [PubMed]
65. Suman, K.; Kalyan, B.; Tanmay, M.; Sanchita, M.; Bhadra, U.K.; Kamalesh, S. Perceived morbidity,
healthcare-seeking behavior and their determinants in a poor-resource setting: Observation from India.
PLoS ONE 2015, 10, e0125865.
66. Wanaratwichit, C.; Sirasoonthorn, P.; Pannarunothai, S.; Noosorn, N. Access to services and complications
experienced by disabled people in Thailand. Asia Pac. J. Public Health 2008, 20, 251–256. [PubMed]
67. Zongjie, Y.; Hong, D.; Zhongxin, X.; Hui, X. A research study into the requiremenst of disabled residents for
rehabilitation services in Beijing. Disabil. Rehabil. 2007, 29, 825–833. [CrossRef] [PubMed]
68. Ahmad, K.; Zwi, A.B.; Tarantola, D.J.M.; Azam, S.I. Eye Care Service Use and Its Determinants in
Marginalized Communities in Pakistan: The Karachi Marine Fishing Communities Eye and General Health
Survey. Ophthalmic Epidemiol. 2015, 22, 370–379. [CrossRef] [PubMed]
69. Brian, G.; Maher, L.; Ramke, J.; Palagyi, A. Eye care in Fiji: A population-based study of use and barriers.
Ophthalmic Epidemiol. 2012, 19, 43–51. [CrossRef] [PubMed]
70. Fletcher, A.E.; Donoghue, M.; Devavaram, J.; Thulasiraj, R.D.; Scott, S.; Abdalla, M.; Shanmugham, C.A.K.;
Murugan, P.B. Low uptake of eye services in rural India: A challenge for programs of blindness prevention.
Arch. Ophthalmol. 1999, 117, 1393–1399. [CrossRef] [PubMed]
71. Kovai, V.; Krishnaiah, S.; Shamanna, B.R.; Ravi, T.; Rao, G.N. Barriers to accessing eye care services among
visually impaired populations in rural Andhra Pradesh, South India. Indian J. Ophthalmol. 2007, 55, 365–372.
[CrossRef] [PubMed]
72. Lee, L.; Ramke, J.; Blignault, I.; Casson, R.J. Changing Barriers to Use of Eye Care Services in Timor-Leste:
2005 to 2010. Ophthalmic Epidemiol. 2013, 20, 45–51. [CrossRef] [PubMed]
73. Mahande, M.; Tharaney, M.; Kirumbi, E.; Ngirawamungu, E.; Geneau, R.; Tapert, L.; Courtright, P. Uptake of
trichiasis surgical services in Tanzania through two village-based approaches. Br. J. Ophthalmol. 2007, 91, 139–142.
[CrossRef] [PubMed]
74. Palagyi, A.; Ramke, J.; du Toit, R.; Brian, G. Eye care in Timor-Leste: A population-based study of utilization
and barriers. Clin. Exp. Ophthalmol. 2008, 36, 47–53. [CrossRef] [PubMed]
75. Udeh, N.N.; Eze, B.I.; Onwubiko, S.N.; Arinze, O.C.; Onwasigwe, E.N.; Umeh, R.E. Oculocutaneous
albinism: Identifying and overcoming barriers to vision care in a Nigerian population. J. Community Health
2014, 39, 508–513. [CrossRef] [PubMed]
76. Bernabe-Ortiz, A.; Diez-Canseco, F.; Vasquez, A.; Kuper, H.; Walsham, M.; Blanchet, K. Inclusion of persons
with disabilities in systems of social protection: A population-based survey and case-control study in Peru.
BMJ Open 2016, 6, e011300. [CrossRef] [PubMed]
77. Borker, S.; Motghare, D.; Kulkarni, M.; Bhat, S. Study of knowledge, accessibility and utilization of the existing
rehabilitation services by disabled in a rural Goan community. Ann. Trop. Med. Public Health 2012, 5, 581–586.
[CrossRef]
78. Eide, A.H. Living Conditions among People with Disabilities in Zimbabwe; SINTEF: Trondheim, Norway, 2003.
79. Eide, A.H.; Van Rooy, G.; Loeb, M.E. Living Conditions among People with Disabilities in Namibia; SINTEF:
Trondheim, Norway, 2003.
80. Eide, A.H.; Kamaleri, Y. Living Conditions among People with Disabilities in Mozambique; SINTEF: Trondheim
Norway, 2009.
81. Eide, A.H.; Jele, B. Living Conditions among People with Disabilities in Swaziland: A National Representative Study;
SINTEF: Trondheim, Norway, 2011.
82. Eide, A.H.; Neupane, S.; Hem, K.G. Living Conditions among People with Disabilities in Nepal; SINTEF:
Trondheim, Norway, 2016.
83. Eide, A.H.; Mmatli, T. Living Conditions among People with Disability in Botswana; SINTEF: Trondheim,
Norway, 2016.
84. Hamdan, M.; Al-Akhras, N. House-to-house survey of disabilities in rural communities in the north of the
West Bank. East. Mediterr. Health J. 2009, 15, 1496–1503. [PubMed]
85. Hosain, G.M.; Chatterjee, N. Health-care utilization by disabled persons: A survey in rural Bangladesh.
Disabil. Rehabil. 1998, 20, 337–345. [CrossRef] [PubMed]
86. Kisioglu, A.N.; Uskun, E.; Ozturk, M. Socio-demographical examinations on disability prevalence and
rehabilitation status in southwest of Turkey. Disabil. Rehabil. 2003, 25, 1381–1385. [CrossRef] [PubMed]
87. Kuper, H.; Nyapera, V.; Evans, J.; Munyendo, D.; Zuurmond, M.; Frison, S.; Mwenda, V.; Otieno, D.; Kisia, J.
Malnutrition and Childhood Disability in Turkana, Kenya: Results from a Case-Control Study. PLoS ONE
2015, 10, e0144926. [CrossRef] [PubMed]
88. Marella, M.; Busija, L.; Islam, F.M.A.; Devine, A.; Fotis, K.; Baker, S.M.; Sprunt, B.; Edmonds, T.J.; Huq, N.L.;
Cama, A.; et al. Field-testing of the rapid assessment of disability questionnaire. BMC Public Health 2014, 14, 900.
[CrossRef] [PubMed]
89. Marella, M.; Devine, A.; Armecin, G.F.; Zayas, J.; Marco, M.J.; Vaughan, C. Rapid assessment of disability
in the Philippines: Understanding prevalence, well-being, and access to the community for people with
disabilities to inform the W-DARE project. Popul. Health Metr. 2016, 14, 26. [CrossRef] [PubMed]
90. Nualnetr, N.; Sakhornkhan, A. Improving Accessibility to Medical Services for Persons with Disabilities in
Thailand. Disabil. CBR Incl. Dev. 2012, 23, 34–49. [CrossRef]
91. Pongprapai, S.; Tayakkanonta, K.; Chongsuvivatwong, V.; Underwood, P. A study on disabled children in a
rural community in southern Thailand. Disabil. Rehabil. 1996, 18, 42–46. [CrossRef] [PubMed]
92. Souza, F.D.; Pimentel, A.M. Pessoas com deficiência: Entre necessidades e atenção à saúde. Cad. Ter. Ocup.
UFSCar 2012, 20, 229–237. [CrossRef]
93. Matheson, J.; Atijosan, O.; Kuper, H.; Rischewski, D.; Simms, V.; Lavy, C. Musculoskeletal Impairment of Traumatic
Etiology in Rwanda: Prevalence, Causes, and Service Implications. World J. Surg. 2011, 35, 2635–2642. [CrossRef]
[PubMed]
94. Kuper, H.; Dok, A.M.V.; Wing, K.; Danquah, L.; Evans, J.; Zuurmond, M.; Gallinetti, J. The Impact of disability
on the lives of children; Cross-sectional data including 8900 children with disabilities and 898,834 children
without disabilities across 30 countries. PLoS ONE 2014, 9, e107300. [CrossRef] [PubMed]
95. Eide, A.H.; Mannan, H.; Khogali, M.; Rooy, G.V.; Swartz, L.; Munthali, A.; Hem, K.G.; MacLachlan, M.;
Dyrstad, K. Perceived barriers for accessing health services among individuals with disability in four African
countries. PLoS ONE 2015, 10, e0125915. [CrossRef] [PubMed]
96. Matter, R.; Harniss, M.; Oderud, T.; Borg, J.; Eide, A.H. Assistive technology in resource-limited environments:
A scoping review. Disabil. Rehabil. 2017, 12, 105–114. [CrossRef] [PubMed]
97. De Silva, M.J.; Lee, L.; Fuhr, D.C.; Rathod, S.; Chisholm, D.; Schellenberg, J.; Patel, V. Estimating the coverage
of mental health programmes: A systematic review. Int. J. Epidemiol. 2014, 43, 341–353. [CrossRef] [PubMed]
98. Jesus, T.S.; Landry, M.D.; Dussault, G.; Fronteira, I. Human resources for health (and rehabilitation): Six
Rehab-Workforce Challenges for the century. Human Resour. Health 2017, 15, 8. [CrossRef] [PubMed]
99. Bruckner, T.A.; Scheffler, R.M.; Shen, G.; Yoon, J.; Chisholm, D.; Morris, J.; Fulton, B.D.; Dal Poz, M.R.;
Saxena, S. The mental health workforce gap in low- and middle-income countries: A needs-based approach.
Bull. World Health Organ. 2011, 89, 184–194. [CrossRef] [PubMed]
100. Bingham, S.; Beatty, P. Rates of access to assistive equipment and medical rehabilitation services among
people with disabilities. Disabil. Rehabil. 2003, 25, 487–490. [CrossRef] [PubMed]
101. Park, S.J.; Jeon, H.J.; Kim, J.Y.; Kim, S.; Roh, S. Sociodemographic factors associated with the use of mental
health services in depressed adults: Results from the Korea National Health and Nutrition Examination
Survey (KNHANES). BMC Health Serv. Res. 2014, 14, 645. [CrossRef] [PubMed]
102. Sakellariou, D.; Rotarou, E.S. Access to healthcare for men and women with disabilities in the UK: Secondary
analysis of cross-sectional data. BMJ Open 2017, 7, e016614. [CrossRef] [PubMed]
103. Harniss, M.; Samant Raja, D.; Matter, R. Assistive technology access and service delivery in resource-limited
environments: introduction to a special issue of Disability and Rehabilitation: Assistive Technology. Disabil.
Rehabil. 2015, 10, 267–270. [CrossRef] [PubMed]
104. World Health Organization. Rehabilitation in Health Systems. 2017. Available online: http://apps.who.int/
iris/bitstream/handle/10665/254506/9789241549974-eng.pdf?sequence=1 (accessed on 18 July 2018).
105. World Health Organization. Task Shifting: Global Recommendations and Guidelines; World Health Organization:
Geneva, Switzerland, 2008.
106. De Swanepoel, W.; Hall, J.W., 3rd. A systematic review of telehealth applications in audiology. Telemed.
e-Health 2010, 16, 181–200. [CrossRef] [PubMed]
107. Foley, A.R.; Masingila, J.O. The use of mobile devices as assistive technology in resource-limited
environments: Access for learners with visual impairments in Kenya. Disabil. Rehabil. 2015, 10, 332–339.
[CrossRef] [PubMed]
108. Sureshkumar, K.; Murthy, G.V.S.; Munuswamy, S.; Goenka, S.; Kuper, H. ‘Care for Stroke’, a web-based,
smartphone-enabled educational intervention for management of physical disabilities following stroke:
Feasibility in the Indian context. BMJ Innov. 2015, 1, 127–136. [CrossRef] [PubMed]
109. Bright, T.; Felix, L.; Kuper, H.; Polack, S. A systematic review of strategies to increase access to health services
among children in low and middle income countries. BMC Health Serv. Res. 2017, 17, 252. [CrossRef]
[PubMed]
110. Bright, T.; Felix, L.; Kuper, H.; Polack, S. Systematic review of strategies to increase access to health services
among children over five in low- and middle-income countries. Trop. Med. Int. Health 2018, 23, 476–507.
[CrossRef] [PubMed]
111. Mactaggart, I.; Kuper, H.; Murthy, G.V.S.; Oye, J.; Polack, S. Measuring Disability in Population Based
Surveys: The Interrelationship between Clinical Impairments and Reported Functional Limitations in
Cameroon and India. PLoS ONE 2016, 11, e0164470. [CrossRef] [PubMed]
112. Peters, D.H.; Garg, A.; Bloom, G.; Walker, D.G.; Brieger, W.R.; Rahman, M.H. Poverty and access to health
care in developing countries. Ann. N. Y. Acad. Sci. 2008, 1136, 161–171. [CrossRef] [PubMed]
© 2018 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

Ijerph 15 02165 v2

Uploaded by

Copyright:

Available Formats

Ijerph 15 02165 v2

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ijerph 15 02165 v2

Uploaded by

Copyright:

Available Formats

International Journal of

2. Materials and Methods

2.1. Eligibility Criteria

2.2. Access to Rehabilitation Defined

2.3. Types of Disability Measures

2.4. Information Sources

2.5. Study Selection

2.6. Data Collection Process

• General study information, including author, year of publication

2.7. Risk of Bias in Individual Studies

Table 1. Quality assessment criteria and ratings.

3.1. Study Selection

results. (LMIC: Low- and Middle-Income Countries).

Table 2. Characteristics of included studies.

3.4. Outcome Types

3.5. Description of Studies

3.5.1. Access to Rehabilitation for Hearing Impairment

Table 3. Access to hearing impairment specific services (D = disability).

3.5.2. Access to Rehabilitation for Mental Impairment

Table 4. Results for studies measuring mental impairments (D = disability).

Country World Proportion Covered by

3.5.3. Access to Rehabilitation for Physical Impairment

Table 5. Results for physical impairment.

Country World Proportion Covered by Type of

3.5.4. Access to Rehabilitation for Vision Impairment

3.5.5. Access to Rehabilitation for Any Disability

Table 6. Results of vision specific services.

Table 7. Access to any rehabilitation.

World Country Means of Proportion Covered by Type of

Table 8. Access to any rehabilitation.

Table 9. Barriers to accessing rehabilitation reported across studies.

4.1. Review of Findings

measure access to rehabilitation, as well as measures of impairment/disability, are varied making

4.2. Consistency with Previous Reviews

4.3. Implications for Practice

4.4. Implications for Research

Use Common Definitions of Disability and Coverage

4.5. Limitations and Strengths

Supplementary Materials: The following are available online at http://www.mdpi.com/1660-4601/15/10/2165/

You might also like