Access to health for persons with disabilities



77001371600540005431155Access to health for persons with disabilities7900035000Access to health for persons with disabilitiesright23002311402018760098002018left88737TOM SHAKESPEARE1TESS BRIGHT2HANNAH KUPER24000020000TOM SHAKESPEARE1TESS BRIGHT2HANNAH KUPER21 Medical School , University of East Anglia, UK2 International Centre for Evidence in Disability, London School of Hygiene & Tropical Medicine, UK.Contents TOC \o "1-3" \h \z \u Introduction PAGEREF _Toc512435180 \h 3Disabled people can be healthy PAGEREF _Toc512435181 \h 4Health care needs of persons with disabilities PAGEREF _Toc512435182 \h 5Healthcare meeting the needs of persons with disabilities PAGEREF _Toc512435183 \h 7Access to healthcare: Universal Health Coverage and Disability PAGEREF _Toc512435184 \h 11Healthcare coverage of persons with disabilities PAGEREF _Toc512435185 \h 13Systematic review of access to healthcare PAGEREF _Toc512435186 \h 15Access to general healthcare services among people with disabilities PAGEREF _Toc512435187 \h 16Summary of findings PAGEREF _Toc512435188 \h 16Data disaggregation and comparability of findings across studies PAGEREF _Toc512435189 \h 18Access to specialist services among people with disabilities PAGEREF _Toc512435190 \h 19Summary of findings PAGEREF _Toc512435191 \h 19Description of findings by impairment type PAGEREF _Toc512435192 \h 20Data disaggregation and comparability of findings across studies PAGEREF _Toc512435193 \h 23Summary of results of the literature review PAGEREF _Toc512435194 \h 23Barriers in accessing healthcare PAGEREF _Toc512435195 \h 25Human rights violations in the context of health care services PAGEREF _Toc512435196 \h 29Overcoming barriers to health care services PAGEREF _Toc512435197 \h 31Improving policy response PAGEREF _Toc512435198 \h 32Improving coverage of services PAGEREF _Toc512435199 \h 34Improving health promotion PAGEREF _Toc512435200 \h 35Improving early identification and intervention PAGEREF _Toc512435201 \h 35Improving access to rehabilitation PAGEREF _Toc512435202 \h 36Improving quality of healthcare services PAGEREF _Toc512435203 \h 37Monitoring inclusion of people with disabilities in healthcare PAGEREF _Toc512435204 \h 37Conclusions PAGEREF _Toc512435205 \h 38Acknowledgements PAGEREF _Toc512435206 \h 39References PAGEREF _Toc512435207 \h 40Appendicies PAGEREF _Toc512435208 \h 48Appendix 1: ICF Model of Disability PAGEREF _Toc512435209 \h 48Appendix 2: Systematic review methodology PAGEREF _Toc512435210 \h 49Appendix 3: Description of studies included in systematic review of access to general healthcare among people with disabilities PAGEREF _Toc512435211 \h 50Appendix 4: Description of studies included in systematic review of access to specialist healthcare among people with disabilities PAGEREF _Toc512435212 \h 52Appendix 5: Primary health service utilisation PAGEREF _Toc512435213 \h 54Appendix 6: Utilisation of hospitals PAGEREF _Toc512435214 \h 56IntroductionThis report was commissioned to provide a general overview of the health status of persons with disabilities, in order to inform the next report of the UN Special Rapporteur on the rights of persons with disabilities for the UN General Assembly. The purpose of this background document is to provide an overview of different topics related to the health of persons with disabilities, including:relationship between disability and health;health care needs of persons with disabilities;?unmet health care needs of persons with disabilities;?barriers in accessing to free or affordable general and disability-specific health care services;barriers in?accessing to free or affordable health-related habilitation and rehabilitation goods and services, including early identification and intervention;human rights violations in the context of health care services.Persons with disabilities have the same health needs as every other member of the population, including immunization, screening, sexual and reproductive health, and all other aspects of regular healthcare. They may also have additional or more complex health needs, because of impairment and the consequences of impairment. Persons with disabilities may face particular barriers in accessing needed healthcare. Not least of these is the increased likelihood of living in a situation of poverty and social exclusion, which increases both the likelihood of ill-health, and the likelihood of facing barriers to accessing healthcare. For all these reasons, health is a disability rights issue, which is why Article 25 of the Convention on the Rights of Persons with Disabilities sets out the normative framework which should govern disabled people’s access to healthcare.Health is important in itself, because it enables a person to have a good life, and a full life expectancy. However, poor health or lack of access to needed healthcare also makes it more difficult for other rights to be realized. If an individual does not have access to needed medical or rehabilitation services, they may be unable to attend school, or access livelihood opportunities, or participate in society. For example, in a study carried out by the London School of Hygiene and Tropical Medicine in Nepal, a major reason why children with disabilities said they weren’t going to school was because of poor health. ADDIN EN.CITE <EndNote><Cite><Author>Zuurmond</Author><Year>2018</Year><RecNum>135</RecNum><DisplayText>[1]</DisplayText><record><rec-number>135</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524560593">135</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Zuurmond, M.</author></authors></contributors><titles><title>Include us in education!</title></titles><dates><year>2018</year></dates><pub-location>London</pub-location><publisher>London School of Hygiene &amp; Tropical Medicine</publisher><urls></urls></record></Cite></EndNote>[1] Those who lack access to wheelchairs, prosthetic or orthotics are likely to face barriers to participation. So, achieving the right of access to health and rehabilitation underpins other social and economic rights.The disability rights movement may sometimes have been reluctant to campaign on the issue of health and rehabilitation, because of concerns about medicalization of disability. Over many decades, the disability rights struggle has been to highlight the role of barriers and oppression in the lives of persons with disabilities, to reject inappropriate medicalization, and to challenge the power of professionals over the lives of persons with disabilities. Whilst persons with disabilities may usually have experienced health conditions and impairments, there has been greater focus on removing societal barriers through the social model of disability to avoid over medicalized views of disability. As a consequence, the role of needed healthcare has sometimes been minimized. However, talking about health and healthcare does not mean being defined by an impairment or health condition. Acknowledging that almost all impairments have a health component does not mean being defined as ‘unhealthy’ or seen as ‘invalid’. Like everyone else, persons with disabilities have health needs. By virtue of their health condition or impairment, they often – but not always – have additional health needs. These should not define them, because to have health needs is part of the human condition.The issue of prevention is also controversial within the disability rights community. There is no difficulty with campaigning for access to health to ensure that persons with disabilities enjoy the right to health on an equal basis with others. Ensuring that persons with disability can access health promotion, prevention, screening, rehabilitation and other mainstream and specialist health services is unquestioned. However, there can be concerns about certain efforts to ensure that non-disabled people can take all available steps to avoid developing impairments themselves. First, health promotion should not use negative images of life with disability to encourage non-disabled people to live healthy or safe lives. Second, preventing existing people becoming disabled is different from preventing future disabled people. Actions around prenatal diagnosis can be particularly complex, and will be addressed in a later paper from the Special Rapporteur. Here it is important to stress that while prenatal sceening has an important role in healthcare, if it is conducted under conditions of informed consent and balanced information, screening messages should not stigmatise life with disability. Parents should be supported to make the choices about testing that are best for them and their family, and all choices should be supported, and all babies should be welcomed and included. Third, prevention of disability in the general population is not a disability rights issue, it is a health issue. Health promotion, immunization, screening and other efforts should be included under the right to health, not as part of efforts to promote, protect and ensure the rights of persons with disabilities.Disabled people can be healthyObjectively, according to the International Classification of Functioning, Disability and Health, all people with disabilities have a health condition (Appendix 1). However, having an impairment does not mean being unhealthy. ADDIN EN.CITE <EndNote><Cite><Author>Shakesphere</Author><Year>2018</Year><RecNum>136</RecNum><DisplayText>[2]</DisplayText><record><rec-number>136</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524563781">136</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Shakesphere, T. </author></authors><secondary-authors><author><style face="normal" font="default" size="10">Riddle, C.</style></author></secondary-authors><tertiary-authors><author>Lexington Books</author></tertiary-authors></contributors><titles><title>Can disabled people be healthy? </title><secondary-title>From Disability Theory to Practice: Essays in Honor of Jerome E. Bickenbach</secondary-title></titles><dates><year>2018</year></dates><urls></urls></record></Cite></EndNote>[2] Moreover, objective health is not the same as subjective health. As the 1948 WHO definition states, health is “a state of physical, mental and social well-being and not merely the absence of disease or infirmity”. Well-being relates to the subjective sense of being healthy. Many people have static impairments – for example, blindness or deafness or a missing limb – but report feeling healthy. Regardless of impairment or illness, people can be in good health, because they eat a good diet, take exercise, get enough sleep, are in a good emotional state, and pursue other healthy behaviours. For example, the United Kingdom (UK) Office for National Statistics published analysis of 2011 Census data from England and Wales on the subject of disability and health ADDIN EN.CITE <EndNote><Cite><Author>Office for National Statistics</Author><Year>2014</Year><RecNum>137</RecNum><DisplayText>[3]</DisplayText><record><rec-number>137</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524563872">137</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Office for National Statistics,</author></authors></contributors><titles><title>How do people rate their General Health? An analysis of general health by disability and deprivation</title></titles><dates><year>2014</year></dates><pub-location>United Kingdom</pub-location><urls></urls></record></Cite></EndNote>[3]: the Census asked people to rate their own health on a five point Likert scale, and it also asked whether respondents’ day-to-day activities were limited because of a health problem or disability which had lasted, or was expected to last, at least 12 months. The results show that 4.3% of the private household population, or 2.4 million people had a disability, but still reported being in good health. There was an age gradient: over 50% of children with disability were in “good” health, whereas at the oldest ages, slightly less than 20% of people with disability were in good health. However, because disability is more common among older people, the overall population of people with good health despite disability was highest among older age people: around one in 6 people aged 85 and over were in good health despite a disability. This is important, because it suggests that some people may report feeling healthy but still have social care needs. A richer understanding of health and disability is required to capture the lived experience of people who have life limiting illnesses or impairments.Health care needs of persons with disabilities?There is good evidence that persons with disabilities are more likely to have poorer health than the general population, due to a variety of possible mechanisms, which may be different for people with different impairments.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Gcm9laGxpY2gtR3JvYmU8L0F1dGhvcj48WWVhcj4yMDE2

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ADDIN EN.CITE.DATA [4-9] First, by definition they have a primary impairment, which may or may not be a health condition which becomes progressively more significant, such as multiple sclerosis or muscular dystrophy. Some impairments do not directly affect health, they could be considered more as differences in functioning – such as Deafness or some aspects of neurodiversity.Secondly, many disabled people are at greater risk of secondary health conditions, where there is a causal link to their primary diagnosis or impairment. For example, people with spinal cord injury are at increased risk of pressure sores and urinary tract infection.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYXJjaWEtQXJndWVsbG88L0F1dGhvcj48WWVhcj4yMDE3

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ADDIN EN.CITE.DATA [10] People with Down’s syndrome are more likely to experience congenital heart disease, impaired hearing and early onset dementia.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NYWx0PC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [11] People with blindness due to diabetes may also experience kidney disease. People with cerebral palsy may develop osteoporosis. ADDIN EN.CITE <EndNote><Cite><Author>Houlihan</Author><Year>2009</Year><RecNum>146</RecNum><DisplayText>[12]</DisplayText><record><rec-number>146</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524564719">146</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Houlihan, C. M.</author><author>Stevenson, R. D.</author></authors></contributors><auth-address>Department of Pediatrics, University of Virginia, 2270 Ivy Road, Charlottesville, VA 22903, USA. ch9g@virginia.edu</auth-address><titles><title>Bone density in cerebral palsy</title><secondary-title>Phys Med Rehabil Clin N Am</secondary-title><alt-title>Physical medicine and rehabilitation clinics of North America</alt-title></titles><periodical><full-title>Phys Med Rehabil Clin N Am</full-title><abbr-1>Physical medicine and rehabilitation clinics of North America</abbr-1></periodical><alt-periodical><full-title>Phys Med Rehabil Clin N Am</full-title><abbr-1>Physical medicine and rehabilitation clinics of North America</abbr-1></alt-periodical><pages>493-508</pages><volume>20</volume><number>3</number><edition>2009/08/01</edition><keywords><keyword>Absorptiometry, Photon</keyword><keyword>Bone Density/*physiology</keyword><keyword>Cerebral Palsy/*complications/rehabilitation</keyword><keyword>Child</keyword><keyword>Fractures, Bone/prevention &amp; control</keyword><keyword>Humans</keyword><keyword>Osteoporosis/diagnosis/*etiology/rehabilitation</keyword><keyword>Prognosis</keyword></keywords><dates><year>2009</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1047-9651</isbn><accession-num>19643349</accession-num><urls></urls><custom2>PMC2836770</custom2><custom6>NIHMS179422</custom6><electronic-resource-num>10.1016/j.pmr.2009.04.004</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[12] People with schizophrenia are at higher risk of diabetes. ADDIN EN.CITE <EndNote><Cite><Author>Al-Atram</Author><Year>2018</Year><RecNum>147</RecNum><DisplayText>[13]</DisplayText><record><rec-number>147</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524564750">147</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Al-Atram, A. A.</author></authors></contributors><auth-address>Department of Psychiatry, College of Medicine, Majmaah University, Al Majmaah, Kingdom of Saudi Arabia. E-mail: a.atram@mu.edu.sa.</auth-address><titles><title>A review of the bidirectional relationship between psychiatric disorders and diabetes mellitus</title><secondary-title>Neurosciences (Riyadh)</secondary-title><alt-title>Neurosciences (Riyadh, Saudi Arabia)</alt-title></titles><periodical><full-title>Neurosciences (Riyadh)</full-title><abbr-1>Neurosciences (Riyadh, Saudi Arabia)</abbr-1></periodical><alt-periodical><full-title>Neurosciences (Riyadh)</full-title><abbr-1>Neurosciences (Riyadh, Saudi Arabia)</abbr-1></alt-periodical><pages>91-96</pages><volume>23</volume><number>2</number><edition>2018/04/18</edition><dates><year>2018</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1319-6138 (Print)&#xD;1319-6138</isbn><accession-num>29664448</accession-num><urls></urls><electronic-resource-num>10.17712/nsj.2018.2.20170132</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[13] Some of these secondary conditions may be iatrogenic, in other words, caused by the treatments they receive for the primary impairment.Third, disabled people are also at higher risk of co-morbidities, where the cause is less direct. Often, a co-morbidity might result from the increased risk of poverty and social exclusion that persons with disability might face. Disabling barriers and isolation can impact persons with disabilities in diverse ways. For example, people with a long-term physical condition are 2-3 times more likely to have a mental health condition such as anxiety or depression. ADDIN EN.CITE <EndNote><Cite><Author>Naylor</Author><Year>2012</Year><RecNum>206</RecNum><DisplayText>[14]</DisplayText><record><rec-number>206</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524666409">206</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Naylor, C. </author><author>Parsonage, M. </author><author>McDaid, D. </author><author>Knapp, M.</author><author>Fossey, M.</author><author>Galea, A. </author></authors><secondary-authors><author>The Kings Fund,</author></secondary-authors></contributors><titles><title>Long-term conditions and mental health: the cost of co-morbidities</title></titles><volume>2018</volume><number>25/04</number><dates><year>2012</year></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>[14] Poor people have higher rates of long term illness, and disabled people are generally at risk of poverty, all of which means they are also more likely to experience other health risks associated with social disadvantage (e.g. poor housing and diet). ADDIN EN.CITE <EndNote><Cite><Author>World Health Organization Commission on Social Determinants of Health</Author><Year>2010</Year><RecNum>149</RecNum><DisplayText>[15, 16]</DisplayText><record><rec-number>149</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524565132">149</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Health Organization Commission on Social Determinants of Health,</author></authors></contributors><titles><title>Closing the gap in a generation: Health equity through action on the social determinants of health</title></titles><volume>2018</volume><number>24/04</number><dates><year>2010</year></dates><urls><related-urls><url> app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608782">99</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Banks, Lena Morgon</author><author>Kuper, Hannah</author><author>Polack, Sarah</author></authors></contributors><titles><title>Poverty and disability in low- and middle-income countries: A systematic review</title><secondary-title>PLOS ONE</secondary-title></titles><periodical><full-title>PLoS ONE</full-title></periodical><pages>e0189996</pages><volume>12</volume><number>12</number><dates><year>2017</year></dates><publisher>Public Library of Science</publisher><urls><related-urls><url>;[15, 16] People with disabilities are more likely to be women and are more likely to be older people, each of which may be associated with health risks. ADDIN EN.CITE <EndNote><Cite><Author>World Bank</Author><Year>2011</Year><RecNum>100</RecNum><DisplayText>[17]</DisplayText><record><rec-number>100</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523609163">100</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Bank,</author><author>World Health Organization,</author></authors></contributors><titles><title>The World Report on Disability</title></titles><volume>2018</volume><number>13/04</number><dates><year>2011</year></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>[17] People with mental health conditions are more likely to experience premature mortality due to higher levels of obesity, smoking, heart disease, high blood pressure, respiratory disease, diabetes and stroke.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYWxrZXI8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [18-20] Older people, for example those with dementia or stroke, are very likely to have more than one condition, which makes medical care more complicated, particularly if they are prescribed multiple drugs, leading to the problem of interactions, or polypharmacy. In general, disabled people have a narrower margin of health, for example they may be at increased risk of dying of influenza in an epidemic. ADDIN EN.CITE <EndNote><Cite><Author>Jackson</Author><Year>2006</Year><RecNum>207</RecNum><DisplayText>[21]</DisplayText><record><rec-number>207</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524666768">207</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jackson, Lisa A.</author><author>Nelson, Jennifer C.</author><author>Benson, Patti</author><author>Neuzil, Kathleen M.</author><author>Reid, Robert J.</author><author>Psaty, Bruce M.</author><author>Heckbert, Susan R.</author><author>Larson, Eric B.</author><author>Weiss, Noel S.</author></authors></contributors><titles><title>Functional status is a confounder of the association of influenza vaccine and risk of all cause mortality in seniors</title><secondary-title>International Journal of Epidemiology</secondary-title></titles><periodical><full-title>International Journal of Epidemiology</full-title></periodical><pages>345-352</pages><volume>35</volume><number>2</number><dates><year>2006</year></dates><isbn>0300-5771</isbn><urls><related-urls><url>;[21]They also often have a greater vulnerability to age-related conditions than persons without disabilities.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Gcm9laGxpY2gtR3JvYmU8L0F1dGhvcj48WWVhcj4yMDE2

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ADDIN EN.CITE.DATA [4] Considering health, structural factors are as important as risks associated with having a disabling health condition. Poor physical and social environments can make primary conditions worse; can exacerbate secondary consequences of primary conditions; and can lead to co-morbidities. For example, as well as poverty and social exclusion, persons with disabilities are also at higher risk of violence: adults have a 50% higher risk of experiencing violence in the past year, rising to 300% higher risk in adults with mental health conditions. ADDIN EN.CITE <EndNote><Cite><Author>Hughes</Author><Year>2012</Year><RecNum>153</RecNum><DisplayText>[22]</DisplayText><record><rec-number>153</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524565720">153</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hughes, K.</author><author>Bellis, M. A.</author><author>Jones, L.</author><author>Wood, S.</author><author>Bates, G.</author><author>Eckley, L.</author><author>McCoy, E.</author><author>Mikton, C.</author><author>Shakespeare, T.</author><author>Officer, A.</author></authors></contributors><auth-address>Centre for Public Health, Liverpool John Moores University, UK.</auth-address><titles><title>Prevalence and risk of violence against adults with disabilities: a systematic review and meta-analysis of observational studies</title><secondary-title>Lancet</secondary-title><alt-title>Lancet (London, England)</alt-title></titles><periodical><full-title>Lancet</full-title></periodical><pages>1621-9</pages><volume>379</volume><number>9826</number><edition>2012/03/02</edition><keywords><keyword>Disabled Persons/*statistics &amp; numerical data</keyword><keyword>Humans</keyword><keyword>Mental Disorders/*epidemiology</keyword><keyword>Prevalence</keyword><keyword>Risk</keyword><keyword>Violence/*statistics &amp; numerical data</keyword></keywords><dates><year>2012</year><pub-dates><date>Apr 28</date></pub-dates></dates><isbn>0140-6736</isbn><accession-num>22377290</accession-num><urls></urls><electronic-resource-num>10.1016/s0140-6736(11)61851-5</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[22] Children have a 300% risk of experiencing violence and abuse, as compared to non-disabled children. ADDIN EN.CITE <EndNote><Cite><Author>Hughes</Author><Year>2012</Year><RecNum>153</RecNum><DisplayText>[22]</DisplayText><record><rec-number>153</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524565720">153</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hughes, K.</author><author>Bellis, M. A.</author><author>Jones, L.</author><author>Wood, S.</author><author>Bates, G.</author><author>Eckley, L.</author><author>McCoy, E.</author><author>Mikton, C.</author><author>Shakespeare, T.</author><author>Officer, A.</author></authors></contributors><auth-address>Centre for Public Health, Liverpool John Moores University, UK.</auth-address><titles><title>Prevalence and risk of violence against adults with disabilities: a systematic review and meta-analysis of observational studies</title><secondary-title>Lancet</secondary-title><alt-title>Lancet (London, England)</alt-title></titles><periodical><full-title>Lancet</full-title></periodical><pages>1621-9</pages><volume>379</volume><number>9826</number><edition>2012/03/02</edition><keywords><keyword>Disabled Persons/*statistics &amp; numerical data</keyword><keyword>Humans</keyword><keyword>Mental Disorders/*epidemiology</keyword><keyword>Prevalence</keyword><keyword>Risk</keyword><keyword>Violence/*statistics &amp; numerical data</keyword></keywords><dates><year>2012</year><pub-dates><date>Apr 28</date></pub-dates></dates><isbn>0140-6736</isbn><accession-num>22377290</accession-num><urls></urls><electronic-resource-num>10.1016/s0140-6736(11)61851-5</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[22] Disabled people also tend to be at higher risk of some unintentional injuries, such as falls or road traffic injury. ADDIN EN.CITE <EndNote><Cite><Author>Shi</Author><Year>2015</Year><RecNum>154</RecNum><DisplayText>[23]</DisplayText><record><rec-number>154</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524565796">154</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shi, Xiuquan</author><author>Shi, Junxin</author><author>Wheeler, Krista K.</author><author>Stallones, Lorann</author><author>Ameratunga, Shanthi</author><author>Shakespeare, Tom</author><author>Smith, Gary A.</author><author>Xiang, Huiyun</author></authors></contributors><titles><title>Unintentional injuries in children with disabilities: a systematic review and meta-analysis</title><secondary-title>Injury Epidemiology</secondary-title></titles><periodical><full-title>Injury Epidemiology</full-title></periodical><pages>21</pages><volume>2</volume><number>1</number><dates><year>2015</year><pub-dates><date>09/15&#xD;06/25/received&#xD;08/18/accepted</date></pub-dates></dates><pub-location>Cham</pub-location><publisher>Springer International Publishing</publisher><isbn>2197-1714</isbn><accession-num>PMC5005703</accession-num><urls><related-urls><url>;[23] Dangerous health behaviours may trigger health conditions associated with disability indirectly: e.g. drug or alcohol abuse may lead to disability as a result of road traffic injury. 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ZE5vdGU+AG==

ADDIN EN.CITE.DATA [4-7, 9] There is also evidence from a study in the United States showing that adults with disabilities are four times more likely to report their health to be fair or poor than people without disabilities (40.3% vs. 9.9%). ADDIN EN.CITE <EndNote><Cite><Author>Altman</Author><Year>2008</Year><RecNum>155</RecNum><DisplayText>[24]</DisplayText><record><rec-number>155</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524566144">155</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Altman, B. </author><author>Bernstein, A. </author></authors><secondary-authors><author>Natioanl Center for Health Statistics,</author></secondary-authors></contributors><titles><title>Disability and health in the United States, 2001–2005.</title></titles><dates><year>2008</year></dates><pub-location>Hyattsville, MD</pub-location><urls></urls></record></Cite></EndNote>[24] These trends are also apparent in poorer settings, although data here is more sparse. As examples, a study across 30 low and middle income countries found that both boys and girls with disabilities were significantly more likely to report a serious illness than children without disabilities.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5LdXBlcjwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [25] A national survey in Guatemala showed that persons with disabilities were more than twice as likely to self-report that they had experienced a “serious health condition” in the last year (47% versus 23%, adjusted Odds Ratio [aOR] 2.8, 95% CI 2.2-3.7). People with disabilities were also three times more likely to report that they had one of 17 different health conditions than those without disabilities (aOR=2.9, 95% CI 2.2-3.8). ADDIN EN.CITE <EndNote><Cite><Author>International Centre for Evidence in Disability</Author><Year>2017</Year><RecNum>142</RecNum><DisplayText>[8]</DisplayText><record><rec-number>142</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524564378">142</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>International Centre for Evidence in Disability,</author></authors></contributors><titles><title>Guatemala National Disability Study ENDIS 2016 Reports</title></titles><volume>2018</volume><number>24/04</number><dates><year>2017</year></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>[8] A South African study found that persons with disabilities were less than half as likely to report excellent or very good health as non-disabled pople; they were nearly four times as likely to report fair or poor health. ADDIN EN.CITE <EndNote><Cite><Author>Moodley</Author><Year>2015</Year><RecNum>57</RecNum><DisplayText>[26]</DisplayText><record><rec-number>57</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">57</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Moodley, J.</author><author>Ross, E.</author></authors></contributors><titles><title>Inequities in health outcomes and access to health care in South Africa: a comparison between persons with and without disabilities</title><secondary-title>Disability &amp; Society</secondary-title></titles><periodical><full-title>Disability &amp; Society</full-title></periodical><pages>630-644</pages><volume>30</volume><number>4</number><dates><year>2015</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>0968-7599</isbn><accession-num>WOS:000355118200010</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://WOS:000355118200010</url><url>;[26] A study in Chile found that people without disabilities were more than twice as likely to report having good health (54%) as people with disabilities (20%). ADDIN EN.CITE <EndNote><Cite><Author>Rotarou</Author><Year>2017</Year><RecNum>119</RecNum><DisplayText>[27]</DisplayText><record><rec-number>119</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523613171">119</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rotarou, Elena S.</author><author>Sakellariou, Dikaios</author></authors></contributors><titles><title>Inequalities in access to health care for people with disabilities in Chile: the limits of universal health coverage</title><secondary-title>Critical Public Health</secondary-title></titles><periodical><full-title>Critical Public Health</full-title></periodical><pages>604-616</pages><volume>27</volume><number>5</number><section>604</section><dates><year>2017</year></dates><isbn>0958-1596&#xD;1469-3682</isbn><urls></urls><electronic-resource-num>10.1080/09581596.2016.1275524</electronic-resource-num></record></Cite></EndNote>[27] Healthcare meeting the needs of persons with disabilitiesDue to the higher vulnerability to health concerns discussed above, on average persons with disabilities are likely to require and use health services more than persons without disabilities. Persons with disabilities require the same general health services as persons without disabilities, from promotion, prevention, and treatment, to rehabilitation and palliative care. People with disabilities may also require different types of specialist services (e.g. rehabilitation or assistive devices) or adaptations in how services are offered (e.g. sign language communication). The World Report on Disability summarises results from the World Health Survey in 50 countries, reporting individuals’ care seeking behaviour by country income level. The analysis found that in low-income countries, a significantly higher proportion of both males and females with disabilities (>18 years) sought inpatient and outpatient care. ADDIN EN.CITE <EndNote><Cite><Author>World Bank</Author><Year>2011</Year><RecNum>100</RecNum><DisplayText>[17]</DisplayText><record><rec-number>100</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523609163">100</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Bank,</author><author>World Health Organization,</author></authors></contributors><titles><title>The World Report on Disability</title></titles><volume>2018</volume><number>13/04</number><dates><year>2011</year></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>[17] A key consideration is whether there is equity in quality of health and healthcare between persons with and without disabilities. Health equity can be divided into vertical health equity – are different groups of people with the same needs treated the same – and horizontal health equity – are people with different needs treated differently according to their health needs. Because the needs of disabled and non-disabled people are not the same, the measure of health equity should not be parity of usage: it should be the extent to which health services meet complex medical and rehabilitation needs of persons with disabilities, i.e. horizontal health equity. For example, the analyses of the World Health Surveys in the World Report on Disability showed that both men and women with disabilities were significantly more likely to report needing healthcare services but not receiving them, then people without disabilities (women: 5.8% versus 3.7%; men: 5.8% versus 4.1%). A Canadian study found that adults with disabilities aged 20-64 had three times the level of unmet healthcare needs as adults without disabilities. ADDIN EN.CITE <EndNote><Cite><Author>McColl</Author><Year>2010</Year><RecNum>156</RecNum><DisplayText>[28]</DisplayText><record><rec-number>156</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524566777">156</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McColl, Mary Ann</author><author>Jarzynowska, Anna</author><author>Shortt, S. E. D.</author></authors></contributors><titles><title>Unmet health care needs of people with disabilities: population level evidence</title><secondary-title>Disability &amp; Society</secondary-title></titles><periodical><full-title>Disability &amp; Society</full-title></periodical><pages>205-218</pages><volume>25</volume><number>2</number><dates><year>2010</year><pub-dates><date>2010/03/01</date></pub-dates></dates><publisher>Routledge</publisher><isbn>0968-7599</isbn><urls><related-urls><url>;[28] Health outcomes are likely to be worse for some persons with disabilities, because some impairments inevitably limit life expectancy, so that there is unlikely ever to be complete health equality. But steadily improving outcomes in terms of quality of life and life expectancy show that barriers are being removed, services are becoming more appropriate, and gaps are being minimized.Discussion of health needs of persons with disabilities should take into account improved technologies, health and social care that are increasingly available to people with different impairments. Sometimes, this is about expensive health interventions which may not be available in resource-constrained settings. For example, life expectancy for people with Down syndrome has increased as they have access to better medical care – such as cardiac surgery, where the survival rate for infants with Down syndrome has been found to be better than that for ‘genetically typical’ infants. ADDIN EN.CITE <EndNote><Cite><Author>Evans</Author><Year>2014</Year><RecNum>157</RecNum><DisplayText>[29]</DisplayText><record><rec-number>157</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524567236">157</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Evans, Jacqueline M.</author><author>Dharmar, Madan</author><author>Meierhenry, Erin</author><author>Marcin, James P.</author><author>Raff, Gary W.</author></authors></contributors><titles><title>Association Between Down Syndrome and In-Hospital Death Among Children Undergoing Surgery for Congenital Heart Disease</title><secondary-title>A US Population-Based Study</secondary-title></titles><periodical><full-title>A US Population-Based Study</full-title></periodical><pages>445-452</pages><volume>7</volume><number>3</number><dates><year>2014</year></dates><urls><related-urls><url>;[29] But in other cases, interventions are comparatively cheap. For example, evidence shows that nocturnal home ventilation is a simple and highly effective intervention for people with Duchenne muscular dystrophy, and it has increased life expectancy from approximately 14 years to upwards of 25 years. ADDIN EN.CITE <EndNote><Cite><Author>Eagle</Author><Year>2002</Year><RecNum>158</RecNum><DisplayText>[30]</DisplayText><record><rec-number>158</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524567375">158</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eagle, M.</author><author>Baudouin, S. V.</author><author>Chandler, C.</author><author>Giddings, D. R.</author><author>Bullock, R.</author><author>Bushby, K.</author></authors></contributors><auth-address>Newcastle Muscle Centre, International Centre for Life, Central Parkway, Newcastle upon Tyne NE1 3BZ, UK.</auth-address><titles><title>Survival in Duchenne muscular dystrophy: improvements in life expectancy since 1967 and the impact of home nocturnal ventilation</title><secondary-title>Neuromuscul Disord</secondary-title><alt-title>Neuromuscular disorders : NMD</alt-title></titles><periodical><full-title>Neuromuscul Disord</full-title><abbr-1>Neuromuscular disorders : NMD</abbr-1></periodical><alt-periodical><full-title>Neuromuscul Disord</full-title><abbr-1>Neuromuscular disorders : NMD</abbr-1></alt-periodical><pages>926-9</pages><volume>12</volume><number>10</number><edition>2002/12/07</edition><keywords><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Home Care Services</keyword><keyword>Humans</keyword><keyword>*Intermittent Positive-Pressure Ventilation</keyword><keyword>*Life Expectancy</keyword><keyword>Male</keyword><keyword>Muscular Dystrophy, Duchenne/epidemiology/*mortality/rehabilitation</keyword><keyword>Retrospective Studies</keyword><keyword>Survival Analysis</keyword><keyword>Time Factors</keyword></keywords><dates><year>2002</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0960-8966 (Print)&#xD;0960-8966</isbn><accession-num>12467747</accession-num><urls></urls><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[30] While evidence-based interventions are generally to be welcomed, there can be concerns about other pioneering treatments for which efficacy may be uncertain, and ethical problems might arise, particularly regarding lack of consent obtained from child subjects of interventions. 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ADDIN EN.CITE.DATA [31-34] In many of these cases, interventions reflect the urge of parents or clinicians to attempt correctivecures or normalization, whereas acceptance of difference and removal of societal barriers will often be a more effective and less damaging response.Often improvements in mortality (life expectancy) and morbidity (experience of impairment) result from comparatively simple interventions which are as much to do with social support and inclusion as they are medicine itself: for example, Worf et al (2011) showed that life expectancy for children with spina bifida in Uganda improves with availability of Community-Based Rehabilitation (CBR). ADDIN EN.CITE <EndNote><Cite><Author>Warf</Author><Year>2011</Year><RecNum>163</RecNum><DisplayText>[35]</DisplayText><record><rec-number>163</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524567782">163</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Warf, B. C.</author><author>Wright, E. J.</author><author>Kulkarni, A. V.</author></authors></contributors><auth-address>Department of Neurosurgery, Children&apos;s Hospital Boston and Harvard Medical School, Boston, Massachusetts 02115, USA. benjamin.warf@childrens.harvard.edu</auth-address><titles><title>Factors affecting survival of infants with myelomeningocele in southeastern Uganda</title><secondary-title>J Neurosurg Pediatr</secondary-title><alt-title>Journal of neurosurgery. Pediatrics</alt-title></titles><periodical><full-title>J Neurosurg Pediatr</full-title><abbr-1>Journal of neurosurgery. Pediatrics</abbr-1></periodical><alt-periodical><full-title>J Neurosurg Pediatr</full-title><abbr-1>Journal of neurosurgery. Pediatrics</abbr-1></alt-periodical><pages>127-33</pages><volume>7</volume><number>2</number><edition>2011/02/03</edition><keywords><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Male</keyword><keyword>Meningomyelocele/*mortality</keyword><keyword>Survival Rate</keyword><keyword>Time Factors</keyword><keyword>Uganda</keyword></keywords><dates><year>2011</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1933-0707</isbn><accession-num>21284456</accession-num><urls></urls><electronic-resource-num>10.3171/2010.11.peds10428</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[35] CBR began as provision of rehabilitation interventions in the community provided by community heath workers, and has evolved into a multi-dimensions approach encompassing health, rehabilitation, education, livelihood, social and empowerment aspects: increasingly, it is known under the term ‘disabilty-inclusive development’. CBR has an important role to play, particularly in identifying children and adults with unmet needs; providing community heath and rehabilitation responses; and referring persons with disabilities to the mainstream health system when those needs cannot be addressed in community settings. CBR can thus contribute to overcoming barriers of access to health and health-related rehabilitation. CBR also works to promote inclusion in education, livelihood and social life, and thereby reduce poverty and discrimination, which are underlying drivers of poor health among people with disabilities. Figure 1 shows the CBR matrix. A systematic review of CBR found a beneficial effect in the lives of persons with physical disabilities and a modest beneficial effect in the lives of persons with mental health conditions or intellectual disabilities, but also found that more and better research was needed. ADDIN EN.CITE <EndNote><Cite><Author>Iemmi</Author><Year>2016</Year><RecNum>164</RecNum><DisplayText>[36]</DisplayText><record><rec-number>164</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524567940">164</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Iemmi, Valentina</author><author>Blanchet, Karl</author><author>Gibson, Lorna J.</author><author>Kumar, K. Suresh</author><author>Rath, Santosh</author><author>Hartley, Sally</author><author>Murthy, Gudlavalleti V. S.</author><author>Patel, Vikram</author><author>Weber, Joerg</author><author>Kuper, Hannah</author></authors></contributors><titles><title>Community-based rehabilitation for people with physical and mental disabilities in low- and middle-income countries: a systematic review and meta-analysis</title><secondary-title>Journal of Development Effectiveness</secondary-title></titles><periodical><full-title>Journal of Development Effectiveness</full-title></periodical><pages>368-387</pages><volume>8</volume><number>3</number><dates><year>2016</year><pub-dates><date>2016/07/02</date></pub-dates></dates><publisher>Routledge</publisher><isbn>1943-9342</isbn><urls><related-urls><url>;[36]Figure 1: CBR matrix ADDIN EN.CITE <EndNote><Cite><Author>Khasnabis</Author><Year>2010</Year><RecNum>208</RecNum><DisplayText>[37]</DisplayText><record><rec-number>208</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524667122">208</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Khasnabis, C.</author><author>Heinicke Motsch, K. </author><author>Achu, K.</author></authors><secondary-authors><author>World Health Organization</author></secondary-authors></contributors><titles><title>Community -Based Rehabilitation: CBR Guidelines</title></titles><dates><year>2010</year></dates><pub-location>Geneva</pub-location><urls></urls></record></Cite></EndNote>[37]To achieve health equity, access to health is a vital prerequisite. Access to health is not just about physical access to a healthcare facility but also covers factors such as ADDIN EN.CITE <EndNote><Cite><Author>Peters</Author><Year>2008</Year><RecNum>131</RecNum><DisplayText>[38]</DisplayText><record><rec-number>131</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523631511">131</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Peters, D. H.</author><author>Garg, A.</author><author>Bloom, G.</author><author>Walker, D. G.</author><author>Brieger, W. R.</author><author>Rahman, M. H.</author></authors></contributors><auth-address>Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Rm. E8132, Baltimore, MD 21205, USA. dpeters@jhsph.edu</auth-address><titles><title>Poverty and access to health care in developing countries</title><secondary-title>Ann N Y Acad Sci</secondary-title><alt-title>Annals of the New York Academy of Sciences</alt-title></titles><periodical><full-title>Ann N Y Acad Sci</full-title><abbr-1>Annals of the New York Academy of Sciences</abbr-1></periodical><alt-periodical><full-title>Ann N Y Acad Sci</full-title><abbr-1>Annals of the New York Academy of Sciences</abbr-1></alt-periodical><pages>161-71</pages><volume>1136</volume><edition>2007/10/24</edition><keywords><keyword>*Developing Countries</keyword><keyword>Health Facilities/supply &amp; distribution</keyword><keyword>Health Services Accessibility/*economics</keyword><keyword>Healthcare Disparities</keyword><keyword>Humans</keyword><keyword>*Poverty</keyword></keywords><dates><year>2008</year></dates><isbn>0077-8923 (Print)&#xD;0077-8923</isbn><accession-num>17954679</accession-num><urls></urls><electronic-resource-num>10.1196/annals.1425.011</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>[38]:QualityGeographical accessibilityAvailabilityFinanancial accessibilityAcceptability of servicesIn other words, having services available, being able to travel to services, being able to get into premises, and access information, and benefit from accessible facilities, being able to have free or reimbursed services, being treated with respect and being able to have high quality and acceptable services is all part of healthcare access, properly understood. However, evidence suggests that people with disabilities face a multitude of barriers to accessing health facilities. As an example, in Namibia, people with disabilities reported difficulties with transportation, having to travel long distances, and inability to afford treatment. ADDIN EN.CITE <EndNote><Cite><Author>Van Rooy</Author><Year>2012</Year><RecNum>165</RecNum><DisplayText>[39]</DisplayText><record><rec-number>165</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524568136">165</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Van Rooy, Gert</author><author>Amadhila, Elina M.</author><author>Mufune, Pempelani</author><author>Swartz, Leslie</author><author>Mannan, Hasheem</author><author>MacLachlan, Malcolm</author></authors></contributors><titles><title>Perceived barriers to accessing health services among people with disabilities in rural northern Namibia</title><secondary-title>Disability &amp; Society</secondary-title></titles><periodical><full-title>Disability &amp; Society</full-title></periodical><pages>761-775</pages><volume>27</volume><number>6</number><dates><year>2012</year><pub-dates><date>2012/10/01</date></pub-dates></dates><publisher>Routledge</publisher><isbn>0968-7599</isbn><urls><related-urls><url>;[39] These types of barriers are expected to be very common in many low and middle income countries. Further, too often, examination couches or scanners or other equipment is not accessible to persons with mobility impairments, for example, and this results in lower quality of examination and treatment.The concept of acceptability highlights how meeting human rights in the area of healthcare does not simply mean ensuring basic health needs are met. It also requires attention to how those healthcare needs are met. Major human rights violations will be discussed later in this paper. But there is also the basic matter of whether persons with disabilities are treated with respect and dignity when they encounter healthcare professionals. This raises several important questions. Are people supported to make decisions for themselves, on the basis of informed consent? Is communication appropriate and accessible? Do persons with disabilities experience ‘diagnostic over-shadowing’, when their general health needs are neglected because of the focus on the primary impairment? Are they supported to get appropriate referrals to address their specific healthcare needs?Access to healthcare: Universal Health Coverage and DisabilityAccess to healthcare is a development issue, as well as a question of realization of rights. A key focus of Sustainable Development Goal 3 “Good Health and Well-being” is to improve access to healthcare services for all through achievement of Universal Health Coverage (UHC). UHC means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. ADDIN EN.CITE <EndNote><Cite><Author>World Health Organization</Author><Year>2018</Year><RecNum>103</RecNum><DisplayText>[40]</DisplayText><record><rec-number>103</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523609855">103</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Health Organization,</author></authors></contributors><titles><title>Universal health coverage and health financing</title></titles><volume>2018</volume><number>13/04</number><dates><year>2018</year></dates><urls><related-urls><url>;[40] Figure 2 illustrates the three dimensions which can affect the achievement of UHC: coverage of (effective) health services, finance, and population. ADDIN EN.CITE <EndNote><Cite><Author>World Health Organization</Author><Year>2015</Year><RecNum>166</RecNum><DisplayText>[40, 41]</DisplayText><record><rec-number>166</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524569212">166</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Health Organization,</author></authors></contributors><titles><title>Universal coverage - three dimensions</title></titles><volume>20018</volume><number>24/04</number><dates><year>2015</year></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>World Health Organization</Author><Year>2018</Year><RecNum>103</RecNum><record><rec-number>103</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523609855">103</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Health Organization,</author></authors></contributors><titles><title>Universal health coverage and health financing</title></titles><volume>2018</volume><number>13/04</number><dates><year>2018</year></dates><urls><related-urls><url>;[40, 41] The smaller blue cube represents current circumstances while the larger cube represents the ideal coverage at which UHC is achieved. Figure 2: The three dimensions to consider when moving towards universal coverage. ADDIN EN.CITE <EndNote><Cite><Author>World Health Organization</Author><Year>2018</Year><RecNum>103</RecNum><DisplayText>[40]</DisplayText><record><rec-number>103</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523609855">103</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Health Organization,</author></authors></contributors><titles><title>Universal health coverage and health financing</title></titles><volume>2018</volume><number>13/04</number><dates><year>2018</year></dates><urls><related-urls><url>;[40]People with disabilities may potentially be left behind across the three aspects of UHC:Population coverage: The population coverage axis of UHC focuses on access to health for all, aiming for health care that is available to the entire population. People with disabilities may experience poorer access to healthcare services and consequently high unmet needs ADDIN EN.CITE <EndNote><Cite><Author>World Bank</Author><Year>2011</Year><RecNum>100</RecNum><DisplayText>[17]</DisplayText><record><rec-number>100</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523609163">100</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Bank,</author><author>World Health Organization,</author></authors></contributors><titles><title>The World Report on Disability</title></titles><volume>2018</volume><number>13/04</number><dates><year>2011</year></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>[17]. Financial coverage: The second component of UHC is that healthcare needs to be affordable, even for the poorest in the community. Financial barriers to accessing healthcare are widespread for many people, but may be exacerbated among persons with disabilities as they are often marginalized, less likely to be employed, and on average are poorer than those without disabilities. ADDIN EN.CITE <EndNote><Cite><Author>Banks</Author><Year>2017</Year><RecNum>99</RecNum><DisplayText>[16]</DisplayText><record><rec-number>99</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608782">99</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Banks, Lena Morgon</author><author>Kuper, Hannah</author><author>Polack, Sarah</author></authors></contributors><titles><title>Poverty and disability in low- and middle-income countries: A systematic review</title><secondary-title>PLOS ONE</secondary-title></titles><periodical><full-title>PLoS ONE</full-title></periodical><pages>e0189996</pages><volume>12</volume><number>12</number><dates><year>2017</year></dates><publisher>Public Library of Science</publisher><urls><related-urls><url>;[16] Furthermore, healthcare costs are often higher for people with disabilities (e.g. accessible transport, need for carer to accompany), which will increase the lack of affordability further. ADDIN EN.CITE <EndNote><Cite><Author>World Bank</Author><Year>2011</Year><RecNum>100</RecNum><DisplayText>[17]</DisplayText><record><rec-number>100</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523609163">100</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Bank,</author><author>World Health Organization,</author></authors></contributors><titles><title>The World Report on Disability</title></titles><volume>2018</volume><number>13/04</number><dates><year>2011</year></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>[17] The World Report on Disability also showed that 51-53% of people with disabilities cannot afford healthcare, compared to 32-33% of people without disabilities, and that persons with disabilities were 50% more likely to experience catastrophic health expenditure which pushed them into poverty. ADDIN EN.CITE <EndNote><Cite><Author>World Bank</Author><Year>2011</Year><RecNum>100</RecNum><DisplayText>[17]</DisplayText><record><rec-number>100</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523609163">100</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Bank,</author><author>World Health Organization,</author></authors></contributors><titles><title>The World Report on Disability</title></titles><volume>2018</volume><number>13/04</number><dates><year>2011</year></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>[17] Service coverage: The service axis of the UHC model focuses on the type of services available. The full range of healthcare services that people with disabilities may need, both general and specialized, should be available in order to achieve truly UHC. Crucially, for people with disabilities, rehabilitation and assistive devices must be explicitly included within essential healthcare services and consideration of achievement of UHC. The WHO estimates in many low-income and middle-income countries, only 5-15% of people who require assistive devices and technologies have access to them. ADDIN EN.CITE <EndNote><Cite><Author>World Health Organization</Author><Year>2018</Year><RecNum>202</RecNum><DisplayText>[42]</DisplayText><record><rec-number>202</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524643899">202</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Health Organization,</author></authors></contributors><titles><title>Assistive Technology</title></titles><volume>2018</volume><number>25/04</number><dates><year>2018</year></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>[42] Coverage is not the same as effective coverage, and the aspect of quality needs to be considered within the UHC framework. Quality of healthcare provision may be a particular concern for people with disabilities, because of stigma and discrimination, presence of comorbidities and consequent need for complex coordinated care and due to inaccessible equipment or lack of skills of healthcare professionals. ADDIN EN.CITE <EndNote><Cite><Author>Shakespeare</Author><Year>2013</Year><RecNum>168</RecNum><DisplayText>[43]</DisplayText><record><rec-number>168</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524569763">168</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shakespeare, Tom</author><author>Kleine, Ira</author></authors></contributors><titles><title>Educating Health Professionals about Disability: A Review of Interventions</title><secondary-title>Health and Social Care Education</secondary-title></titles><periodical><full-title>Health and Social Care Education</full-title></periodical><pages>20-37</pages><volume>2</volume><number>2</number><dates><year>2013</year><pub-dates><date>2013/10/01</date></pub-dates></dates><publisher>Routledge</publisher><isbn>null</isbn><urls><related-urls><url>;[43] It is therefore important to consider healthcare access for people with disabilities, to assess whether their rights are being fulfilled and also whether they are being left behind on the path towards UHC. Healthcare coverage of persons with disabilities?A fundamental concern in discussing healthcare coverage of people with disabilities is that we do not have clear and consistent metric for how this concept can be measured. A lack of measurement tools is not merely an academic issue; different ways of measuring access will give us different answers as to whether or not people with disabilities are excluded from healthcare, and consequently what our policy and programme response should be. This issue is illustrated using the case study below from Guatemala. Access to health was explored within the context of a national survey of disability in Guatemala. ADDIN EN.CITE <EndNote><Cite><Author>International Centre for Evidence in Disability</Author><Year>2017</Year><RecNum>142</RecNum><DisplayText>[8]</DisplayText><record><rec-number>142</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524564378">142</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>International Centre for Evidence in Disability,</author></authors></contributors><titles><title>Guatemala National Disability Study ENDIS 2016 Reports</title></titles><volume>2018</volume><number>24/04</number><dates><year>2017</year></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>[8] This survey included 707 people with disabilities and 465 people without disabilities matched by age, sex and location. Different methods were used to measure access to health, and this fundamentally influenced our judgment as to whether people with disabilities received better, worse or no different access to healthcare than people without disabilities, as summarized in table 1. Table 1: Healthcare access in relation to disability in Guatemala Method for measurement of healthcare accessMain resultInterpretation: Access to healthcare by disability Sought care when had a “serious health condition”76% of people with disabilities had sought care versus 72% of people without disabilities (difference not statistically significant)No differenceReceiving treatment if diagnosed with one of 17 health conditionsPeople with disabilities were more likely to be receiving treatment than people without disabilities (aOR 1.4, 1.0-1.9).Better access among people with disabilitiesVaccination coverageHigh coverage among children with disabilities (94%) and those without (88%) (difference not statistically significant). No differenceReceiving antenatal careWomen with disabilities were significantly less likely to seek antenatal care (aOR 0.4, 0.1-1.0).Worse access among people with disabilitiesDelivery assisted by doctor/nurseWomen with disabilities were more likely to have delivery assisted by a doctor/nurse rather than a non-medical professional (aOR 2.9, 1.0-8.2)Better access among people with disabilitiesCoverage of rehabilitation servicesVery few people with disabilities had received these servicesPoor access among people with disabilities Quality, availability and affordability are crucial, as well as access or coverage. The Guatemala survey did not specifically measure affordability of care, but did find people with disabilities were more likely to report that availability of services was a big problem (table 2). They were also more likely to report being disrespected by health professionals and finding information difficult to understand during their most recent healthcare visit.Table 2: Quality of healthcare experience in relation to disability in GuatemalaMeasure of qualityPersons with disabilitiesPersons without disabilitiesaOR (95% CI)Availability of health services a big problem88 (19%)88 (19%)1.9 (1.4-2.6)Experience last time received health careFelt completely/mostly disrespected47 (9%)13 (4%)1.9 (1.0-3.7)*Difficult to understand information 121 (22%)42 (14%)1.6 (1.1-1.4)*Difficult to be understood 106 (20%)43 (14%)1.3 (0.8-1.9)This example from Guatemala therefore illustrates the complexity of measuring access to healthcare. It also shows that different results are obtained when different metrics are used.Access to healthcare for people with disabilities is an important issue for achieving their human rights, and for achieving development targets such as the Sustainable Development Goals. Disaggregated data are needed to assess whether people with disabilities are being left behind in inclusion in healthcare. The complexity in measuring access and lack of standard measures that would allow comparability of findings must be kept in mind while assessing the findings from the literature.Systematic review of access to healthcare Two of the current authors conducted a systematic review to assess access to healthcare among people with disabilities in low and middle income countries, to explore these questions in more detail and across the full spectrum of published literature available. The key methodological features of the review are summarized in Appendix 2. In brief, over 13,000 titles were screened for eligibility. The review assessed separately access of people with disabilities to general healthcare (49 studies included), and to specialist healthcare (80 studies included). Access to general healthcare services among people with disabilitiesSummary of findingsThe review of access to general health for people with disabilities identified six main outcome types: utilisation, coverage, adherence, affordability, health insurance and quality. Comparisons were made between people with and without disabilities for each outcome. Results of each study were summarized in to higher, lower, mixed (e.g. if results were higher for one disability type and lower for another), and no difference. The results of the 49 included studies are summarised by outcome in Figure 3. Figure 3: Results by outcome typeIn summary, the results showed the following:Utilisation of healthcare services was measured using a range of outcomes in two main groups: use of primary or secondary health services, and use of tertiary services, and by different time periods of assessment. Examples include: number of visits to health centre or public health facility in past 12 months or 2-3 months; access to services in the past 6 months; home visits by a doctor in past 12 months; length of time since last consultation; hospital outpatient visit in the previous 6 or one month; hospitalisations (inpatient admission) in the past 12, 6, or 3 months. Overall, 33% of studies showed that utilisation of healthcare services was higher for people with disabilities compared to those without; 14% showed lower utilisation, 43% showed mixed results, and 10% found no difference. Coverage of healthcare services refers to receipt of treatment when needed, either in terms of need for routine services (e.g. vaccination) or need for services as a result of a health concern (e.g. care when ill). A wide variety of outcomes were used to measure coverage and these included: probability of not receiving care last time needed; help sought when ill in past 30 days, in the past 12 months, or over an unspecified time; and uptake of specific services, (e.g. HIV related, vaccination, dental visits, maternal health). Overall, 43% of studies measuring coverage (n=21) found lower coverage amongst people with disabilities in comparison to people without. A similar proportion found no difference (41%) and 23% found mixed results. Due to the range of outcome measures,it is difficult to compare data. The most consistent finding is among the studies that measured coverage of dental services among children with intellectual impairments; three found lower previous dental attendance for children with intellectual impairment in Nigeria, Egypt, and Jordan respectively, with one finding no difference in any dental treatment received amongst children with Down’s Syndrome in Malaysia. ADDIN EN.CITE <EndNote><Cite><Author>Rahim</Author><Year>2014</Year><RecNum>70</RecNum><DisplayText>[44]</DisplayText><record><rec-number>70</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">70</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rahim, F. S. A.</author><author>Mohamed, A. M.</author><author>Nor, M. M.</author><author>Saub, R.</author></authors></contributors><titles><title>Dental care access among individuals with Down syndrome: a Malaysian scenario</title><secondary-title>Acta Odontologica Scandinavica</secondary-title></titles><periodical><full-title>Acta Odontologica Scandinavica</full-title></periodical><pages>999-1004</pages><volume>72</volume><number>8</number><dates><year>2014</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0001-6357</isbn><accession-num>WOS:000344330400062</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://WOS:000344330400062</url><url>;[44]Adherence to treatment is important since nonadherence leads to poor health outcomes. Good adherence indicates sustained and regular contact with health services.Adherence was measured in three studies – either to HIV treatment, fluid or diet restrictions for end stage renal disease, or medication. Of these studies, two found mixed results by impairment type, and one found adherence was lower than in people without disabilities. Affordability of services is a core component of access to healthcare. In total, six studies measured outcomes related to health expenditure in people with and without disabilities. Costs or expenditure outcomes included catastrophic health expenditure ; total out of pocket expenditure ; and health expenditure to income ratio. Three studies (50%) found higher expenditure among people with disabilities, one study (17%) found no difference, and two studies (33%) found mixed results by impairment type. Health insurance is a key mechanism by which the right to access healthcare can be realized, as it reduces financial constraints to seeking care. Four studies measured outcomes related to health insurance coverage. Access to health insurance was measured in two main ways – medical payment method or provider; or coverage. One study found lower coverage amongst people with disabilities, and three studies found no difference in coverage for people with or without disabilities. Quality of services was assessed in two studies through: ease of access, satisfaction, and overall accessibility. Trani et al. (2012) found no difference in satisfaction with public health facilities in Afghanistan for people aged >5 years with and without disabilities. ADDIN EN.CITE <EndNote><Cite><Author>Trani</Author><Year>2012</Year><RecNum>80</RecNum><DisplayText>[45]</DisplayText><record><rec-number>80</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">80</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Trani, J. F.</author><author>Barbou-des-Courieres, C.</author></authors></contributors><auth-address>J.-F. Trani, Brown School of Social Work, Washington University, St Louis, MO, United States. E-mail: jtrani@wustl.edu</auth-address><titles><title>Measuring equity in disability and healthcare utilization in Afghanistan</title><secondary-title>Medicine, Conflict and Survival</secondary-title></titles><periodical><full-title>Medicine, Conflict and Survival</full-title></periodical><pages>219-246</pages><volume>28</volume><number>3</number><keywords><keyword>adolescent</keyword><keyword>adult</keyword><keyword>Afghanistan</keyword><keyword>article</keyword><keyword>child</keyword><keyword>disabled person</keyword><keyword>female</keyword><keyword>*health care delivery</keyword><keyword>health care survey</keyword><keyword>*health service</keyword><keyword>human</keyword><keyword>male</keyword><keyword>middle aged</keyword><keyword>poverty</keyword><keyword>preschool child</keyword><keyword>statistics</keyword><keyword>utilization review</keyword></keywords><dates><year>2012</year></dates><pub-location>United Kingdom</pub-location><publisher>Routledge (4 Park Square, Milton Park, Abingdon, Oxfordshire OX14 4RN, United Kingdom)</publisher><isbn>1362-3699</isbn><urls><related-urls><url>;[45] In Thailand, a study by Wongkongdech et al. (2014) found that 66% of people with physical impairment of all ages ranked their accessibility to health services at a moderate level (i.e. neither high nor low), taking in to account adequacy of health personnel, respect for rights and dignity, transport, service related aspects, personal factors and costs.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Xb25na29uZ2RlY2g8L0F1dGhvcj48WWVhcj4yMDE0PC9Z

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ADDIN EN.CITE.DATA [46] The use of different metrics for measuring healthcare access may therefore produce inconsistent findings and makes assessment of trends across the literature difficult. Furthermore, there were big gaps in evidence. Health promotion and preventive services are crucial to maintain good health. However, we did not include health promotion in the review as we were concerned that it was difficult to determine whether knowledge was indicative of receipt of health promotion. Furthermore, few studies addressed whether preventive services were reaching people with disabilities. In addition, there was a gap in evidence around access to palliative care for people with disabilities. Data disaggregation and comparability of findings across studiesPeople with disabilities are not a homogenous group, and characteristics such as gender, age and impairment type are likely to impact on access to healthcare services. Very few of the individual studies included in the review disaggregated the data by these characteristics. For the majority of other studies, the numbers in each category became too small to make meaningful inferences about differences by these cross-cutting characteristics. It was also impossible to compare the findings across studies to identify consistent patterns, since there was too much variation in how healthcare access was measured, as well as the study designs, settings (e.g. clinical or population based) and so on. Developing common metrics for measuring healthcare access, and using these in large-scale studies, will improve the availability of high-quality, comparable data, so that the impact of these intersecting issues on healthcare access can be explored. Access to specialist services among people with disabilities Summary of findingsPeople with disabilities may benefit from specialist services as a result of their impairment, which includes physical therapty, assistive devices, speech and language therapy, psychiatry and more. Many of these services are usually known as “rehabilitation”: It should be noted that this is a complex concept to define. The same term is also used for vocational rehabilitation, rehabilitation of offenders, drug and alcohol rehabilitation. Article 26 of the Convention on the Rights of Persons with Disabilities uses an expansive conception of rehabilitation. In this paper, we refer to health-related rehabilitation only. WHO defines rehabilitation 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”. Using this definition, a broad range of interventions that may be required to maximise functioning were included under “rehabilitation” for the review, including: access to medical rehabilitation, access to therapy, coverage of assistive devices, and adherence to medication. These interventions are mainly operating at the level of the individual child or adult with disability. People with impairments that cannot be cured may have improved functioning through the provision of rehabilitation. Coverage of rehabilitation would therefore be the proportion of people needing rehabilitation who have received it. The reality of making this measure is more complex. Measuring coverage of rehabilitation and assistive devices requires a clinical assessment of whether curative treatment is possible (e.g. someone visually impaired from cataract will need surgery, not rehabilitation). Then, assessment of the rehabilitation or assistive device needed and whether this has been received. Estimation of the latter measure is challenging, since it must take into account, for instance that people who have been given an assistive device are still using it, or that the full therapy sessions are provided if needed. Self-report tools may therefore be inadequate to measures of the need for and coverage of rehabilitation. In the studies included in the review, all measured coverage of rehabilitation in terms of self-reported usage versus need. There are therefore serious concerns about the quality and accuracy of data on coverage of rehabilitation services obtained through the systematic review. Description of findings by impairment typeResults of the 80 included studies are presented below by access to services specific to the following disability domains: hearing, mental health, physical, and visual. Coverage of rehabilitation for people with mental or behavioural conditions36 studies measured access to specialist healthcare services for people with mental health and behavioural disorders in 18 countries across six World Bank regions. There was a wide variation in underlying condition for the study population (depression, CP, schizophrenia, epilepsy, intellectual disability, psychiatric disorders, general mental disorders). The majority of studies were conducted amongst adults (22 studies) and most studies sampled participants from the general population (28 studies). There was also a lot of variety in measures of access to rehabilitation used: 26 measured non-pharmaceutical rehabilitation, seven measured adherence to treatment, and four measured access to medication. The broad range of conditions, source of participants, outcomes, and age groups mean that estimates within this group cannot be directly compared. Moreover, the way in which coverage was measured through self-reported usage versus need means that the estimates are of little meaning. However, it was clear that coverage of all coverage of rehabilitation was generally low across studies. As examples:Coverage of medical rehabilitation for depression ranged from 0% for males in Mexico to 53% in South Africa. Coverage of epilepsy treatments ranged from 0% for older adults in Zimbabwe, to 52% amongst people of all ages in The Gambia. For children with intellectual disabilities coverage of rehabilitation services was higher, between 73-87% in Ethiopia and India. For other less specific conditions, coverage of medical rehabilitation ranged from 1% in China (all ages) to 39% for adults in Georgia. Coverage of rehabilitation for people with physical impairment 24 studies measured coverage of physical impairment specific services in 20 countries and five World Bank regions. The types of physical impairments varied, including rheumatoid or other arthritis (five studies), leprosy (two studies), difficulties walking (six studies), amputation (one study), and musculoskeletal impairment (three studies). Five studies were conducted amongst adults, 12 amongst people of all ages, four amongst children and in three studies the age group was not presented. Outcomes included coverage of physical therapy, assistive devices, medical rehabilitation, and adherence. As with rehabilitation for mental health conditions, the wide variety in range of conditions, source of participants, outcomes, and age groups mean that estimates within this group cannot be directly compared and coverage varied widely across studies. Again, the method for measuring coverage casts serious concerns on the validity of the results. As examples:Coverage results for arthritis were varied, with the highest coverage seen in Jordan (76%) and lowest in India (4%). Results were also varied for less specific physical impairments such as “difficulties walking”, musculoskeletal impairment, and physical impairment – with particularly low coverage of assistive devices found in Tanzania (0-4%) and rehabilitation in Brazil (18%), and high coverage found in Rwanda (87%) for physical therapy. Coverage of rehabilitation for people with vision impairment In total, 16 studies measured access to health for people with visual impairment across 13 countries in four World Bank regions. Eleven studies measured medical rehabilitation, six studies measured access to assistive devices, and one study measured adherence. All but two studies used a population-based sample. Coverage of medical rehabilitation was varied – from 5% amongst people of all ages in Brazil to 82% amongst people of all ages in Nigeria. Similarly, results for assistive device coverage were very variable, but typically quite low across studies. There were some outliers, however, with a Nigerian study finding a coverage of 82%. As in the previous examples, the validity of the measures used for coverage is questionable, and so results are not reliable: for example, it is most likely that in practice, coverage of medical rehabilitation is better in Brazil than in Nigeria due its more extensive healthcare system.Coverage of rehabilitation for people with hearing impairment In total 13 studies measured access to hearing specific services in 12 countries, and four World Bank regions. Of these, nine studies measured coverage of assistive devices (hearing aids), five studies measured access to medical rehabilitation, and one measured adherence. Coverage of assistive devices ranged from 0-66% across studies. General rehabilitation coverage was between 3-62%, while one study reported adherence at 34%. Coverage of rehabilitation for people with any disability Overall, 25 studies did not disaggregate results by impairment type, or reported overall coverage in addition to impairment specific coverage, and thus were grouped together under access to any specialist treatment for disabilities, which included access to assistive devices (16 studies), general rehabilitation (22 studies), and adherence (one study). These studies were conducted in 23 countries in 6 regions – the majority in sub-Saharan Africa (12 studies). Ten studies sampled participants from the population. 21 used self-reported tools, including 14 used the Washington Group questions, two used the Rapid Assessment of Disability, and the remaining using bespoke tools. Only two studies out of 25 used a clinical examination, and so it is not possible to infer from this information what the true coverage was of rehabilitation services. Coverage of general rehabilitation was very varied across studies ranging from 3-80%. Coverage was particularly low in India and Turkey at 3 and 5% respectively (both low-middle income). In contrast studies in the Philippines, South Africa, Malaysia, and Brazil found much higher coverage at 70%, 71%, 76%, and 80%. Substantial variation was also found for access to assistive devices – but generally coverage was low. Data disaggregation and comparability of findings across studiesThe coverage results for rehabilitation are hard to compare across studies – different types of impairment are considered, as well as varying measures of coverage, age groups, selection of sample (e.g. population-based versus clinic-based). Individual studies attempted to disaggregate by variables such as age and gender, but the numbers often became small and the inconsistency in methods used makes it impossible to compare disaggregated data across studies.Better metrics are needed to measure need for and coverage of rehabilitation. Self-reported measures are inadequate, as individuals are unlikely to be able to determine which services they require. The Washington Group questions are also insufficient to measure need for rehabilitation, as they do not assess which conditions would benefit from assistive devices or rehabilitation services. For instance, a recent survey in Cameroon found that the most common cause of hearing loss was impacted ear wax, which requires simple removal and not a hearing aid.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GZXJyaXRlPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48

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ADDIN EN.CITE.DATA [48] Furthermore, the Washington Group questions are inconsistent in whether they take consideration of the presence of assistive devices in terms of whether difficulties in functioning are experienced: difficulties in hearing and vision are asked “even if” spectacles or a hearing aid are available, but difficulties in mobility do not consider the presence of assistive devices. Another important issue is that most people will not know that they could benefit from a type of assistive device or rehabilitation service unless they had been offered it in the past. Consequently, measuring coverage in terms of usage of services that the person perceived he/she needed will over-estimate the coverage and not give a meaningful measure of the true need or the true coverage in the population.Clinical assessment of impairments is optimal for determining the need for rehabilitation, but can be costly and take time, and often requires the expertise of health professionals. The more widespread availability of mobile tools to measure visual and hearing impairment and their cause may make clinical assessments more feasible in the future (e.g. Portable Eye Examination Kit (PEEK), hearScreen).PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYXN0YXdyb3VzPC9BdXRob3I+PFllYXI+MjAxNTwvWWVh

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ADDIN EN.CITE.DATA [49, 50] Summary of results of the literature reviewThere is limited evidence that persons with disabilities have worse access to general healthcare services than people without disabilities. We can propose different reasons for this conclusion, but it requires further research. There is a lack of high quality data capturing coverage fully, rather than utilization alone. Use of such crude indicators may mean that we are not able to discern differences in access to healthcare between people with and without disabilities. Another possibility is that if people have a real need for treatment they will attend for services, even if people with disabilities may face more difficulties in achieving access. For instance, in the Guatemala survey the majority of people sought treatment for a “serious health condition” whether disabled or not, and similarly, almost all children were immunized, regardless of disability. As a consequence, these broad measures will not allow us to distinguish access to healthcare in different groups. A related point is that in poor settings there may be general widespread lack of access to healthcare services, and so it may be difficult to identify a difference between persons with and without disabilities. People with disabilities may be more linked in with the healthcare system, because of their impairment and various health conditions, and that helps to overcome some of the barriers they experience in accessing healthcare. There is some evidence from the systematic review that the cost of seeking treatment is higher, and that quality of services/healthcare experience may be worse for persons with disabilities. There is also some evidence that access to rehabilitation is low among persons with disabilities – so that they are not receiving the care they need and have the right to. This review has highlighted that further research is needed to understand how people with disabilities are accessing health services, not just in terms of utilisation, but also coverage of preventive services, affordability of health services, and the quality of care received. In particular, there is a need to define a broader range of metrics to allow collecting more meaningful data and greater comparability of outcomes across countries. Utilisation alone is not an appropriate indicator for people with disabilities, given that people with disability generally experience greater health needs. Coverage of 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. People with disabilities are not a homogenous group, but include people with different impairment types, age, level of poverty, gender, ethnicity and so on. All of these factors can influence the relationship between disability and healthcare access. As mentioned, it was not possible to draw out broad patterns of access by these intersecting issues due to the lack of consistency in how data was collected. There are also specific groups that may be particularly hidden and/or under-represented in the data, such as people with autism, those with psychosocial disabilities or rare diseases, who may face even more exclusion and discrimination within healthcare settings and so may have particularly poor levels of coverage. Another concern is that not all settings are the same. As an example, humanitarian crises can result in people developing impairments, but may also make it more difficult for people with disabilities to seek healthcare and rehabilitation. Yet evidence on the inclusion of people with disabilities in healthcare in these settings is extremely limited. UHC strives to achieve health for all, leaving no one behind, and without more inclusive indicators, we will not be able to monitor progress towards this end. This review found evidence that UHC is not being met for people with disabilities, as they may be falling behind in terms of coverage of general healthcare services, as well as rehabilitation, and services are not affordable or of sufficient quality. Barriers in accessing healthcareThis section will explore barriers which persons with disabilities experience to free or affordable general and disability-specific health care services, including health-related habilitation and rehabilitation goods and services, including early identification and interventionPersons with disabilities are faced with a range of barriers when they seek healthcare. Strategies are required to overcome these different barriers in order to achieve UHC and the fulfilment of rights. People with disabilities are a diverse group, and people withdifferent impairment types may be particularly vulnerable to certain types of barriers to accessing services. Barriers will also vary in different geographic and cultural settings and in different policy environments. A barrier that is perhaps conceptually straightforward arises from limited physical access to healthcare facilities. Obstacles can make it difficult to gain entry into the facility, but also to move through elevators or doorways into treatment rooms, or use the bathrooms. Having accessible/adaptable furniture or equipment is also an important consideration. If these are not available, people with disabilities may not be examined, or not to the same standards as others. For example, a pregnant physically disabled woman may not be able to get onto a bed for antenatal checks easily or may not feel safe. Lack of accessible transport, or lack of nearby facilities, may also limit people with disabilities’ access to health services. Other types of barriers may be less well recognised and understood. For example, for people who are deaf or have other communication difficulties (e.g. cognitive or psychosocial impairments) may miss out on information or on being informed about their options if there is a lack of sign language or other adapted communication tools (easy read information, pictures, symbols). People with visual impairment may not be able to read letters from health professionals or instructions regarding medication.Negative attitudes can also be an important barrier to people with disabilities accessing healthcare. Stigma against people with disabilities is perceived to be widespread, and may discourage people from attending for healthcare services. This experience can be even further complicated by the person with a disability belonging to a certain racial or ethnic minority group, exemplifying the intersectional aspects of disadvantage. ADDIN EN.CITE <EndNote><Cite><Author>Grech</Author><Year>2016</Year><RecNum>209</RecNum><DisplayText>[51]</DisplayText><record><rec-number>209</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524667416">209</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Grech, S. </author><author>Soldatic, K.</author></authors></contributors><titles><title>Disability in the Global South: The Critical Handbook</title><secondary-title>International Perspectives on Social Policy, Administration and Practice</secondary-title></titles><dates><year>2016</year></dates><publisher>Springer</publisher><urls></urls></record></Cite></EndNote>[51] Stigma may also result in many people with disabilities being completely excluded from certain healthcare initiatives. For example, people with disabilities are often incorrectly considered not to be sexually active and may not receive education and care regarding sexual and reproductive health needs.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UZXBwZXI8L0F1dGhvcj48WWVhcj4yMDAwPC9ZZWFyPjxS

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ADDIN EN.CITE.DATA [52, 53] This may also result in low uptake of certain services by people with disabilities, and be wrongly interpreted as lack of need, rather than resulting from exclusion or barriers to access. In Argentina, barriers to accessing reproductive health interventions for women with disabilities - such as contraception, voluntary sterilization, abortion after rape - included long delays, unnecessary referrals, downright denial, need for husband’s permission, were reported by Human Rights Watch. ADDIN EN.CITE <EndNote><Cite><Author>Human Rights Watch</Author><Year>2010</Year><RecNum>171</RecNum><DisplayText>[54]</DisplayText><record><rec-number>171</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524582535">171</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>Human Rights Watch,</author></authors></contributors><titles><title>Illusions of Care: Lack of Accountability for Reproductive Rights in Argentina</title></titles><volume>2018</volume><number>24/04</number><dates><year>2010</year></dates><urls><related-urls><url>;[54]Cost are another major hurdle to accessing healthcare. This barrier arise because people with disabilities are on average poorer, yet face higher healthcare costs, for instance, through needing accessible transport, a companion for the visit, or more expensive treatments. The systematic review included assessment of barriers to accessing general healthcare and rehabilitation among the included studies. Eight studies measured barriers to accessing general healthcare services. The most commonly reported barriers across studies were transport difficulties, financial difficulties and attitudes of staff. These results are shown in Table 3. Table 3: Quantitative barriers to general healthcare reported in included studies?ReferenceGeographic accessibility?Transport difficultiesPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbCBIYWJhc2huZWg8L0F1dGhvcj48WWVhcj4yMDEyPC9Z

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ADDIN EN.CITE.DATA [17, 55-58]?Location of services? ADDIN EN.CITE <EndNote><Cite><Author>Badu</Author><Year>2016</Year><RecNum>10</RecNum><DisplayText>[59]</DisplayText><record><rec-number>10</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">10</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Badu, E.</author><author>Opoku, M. P.</author><author>Appiah, S. C. Y.</author></authors></contributors><titles><title>Attitudes of health service providers: The perspective of people with disabilities in the Kumasi Metropolis of Ghana</title><secondary-title>African Journal of Disability</secondary-title></titles><periodical><full-title>African Journal of Disability</full-title></periodical><volume>5</volume><number>1</number><dates><year>2016</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>2223-9170</isbn><accession-num>WOS:000381752600001</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://WOS:000381752600001</url><url> a181</custom7><electronic-resource-num>10.4102/ajod.v5i1.181</electronic-resource-num></record></Cite></EndNote>[59]Affordability?Financial?PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbCBIYWJhc2huZWg8L0F1dGhvcj48WWVhcj4yMDEyPC9Z

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ADDIN EN.CITE.DATA [17, 55-57, 60]No accommodation at health facility? ADDIN EN.CITE <EndNote><Cite><Author>Eide</Author><Year>2015</Year><RecNum>24</RecNum><DisplayText>[57]</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">24</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eide, A. H.</author><author>Mannan, H.</author><author>Khogali, M.</author><author>Rooy, G. van</author><author>Swartz, L.</author><author>Munthali, A.</author><author>Hem, K. G.</author><author>MacLachlan, M.</author><author>Dyrstad, K.</author></authors></contributors><auth-address>San Francisco</auth-address><titles><title>Perceived barriers for accessing health services among individuals with disability in four African countries</title><secondary-title>PLoS ONE</secondary-title></titles><periodical><full-title>PLoS ONE</full-title></periodical><pages>e0125915</pages><volume>10</volume><number>5</number><keywords><keyword>disabilities</keyword><keyword>education</keyword><keyword>health care</keyword><keyword>health services</keyword><keyword>households</keyword><keyword>men</keyword><keyword>poverty</keyword><keyword>questionnaires</keyword><keyword>research workers</keyword><keyword>screening</keyword><keyword>socioeconomic status</keyword><keyword>socioeconomics</keyword><keyword>sociology</keyword><keyword>UN</keyword><keyword>women</keyword></keywords><dates><year>2015</year></dates><pub-location>USA</pub-location><isbn>1932-6203</isbn><urls><related-urls><url>;[57]Acceptability?Lack of perceived need?PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FaWRlPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [55, 57]Faith/belief? ADDIN EN.CITE <EndNote><Cite><Author>Eide</Author><Year>2015</Year><RecNum>24</RecNum><DisplayText>[57]</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">24</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eide, A. H.</author><author>Mannan, H.</author><author>Khogali, M.</author><author>Rooy, G. van</author><author>Swartz, L.</author><author>Munthali, A.</author><author>Hem, K. G.</author><author>MacLachlan, M.</author><author>Dyrstad, K.</author></authors></contributors><auth-address>San Francisco</auth-address><titles><title>Perceived barriers for accessing health services among individuals with disability in four African countries</title><secondary-title>PLoS ONE</secondary-title></titles><periodical><full-title>PLoS ONE</full-title></periodical><pages>e0125915</pages><volume>10</volume><number>5</number><keywords><keyword>disabilities</keyword><keyword>education</keyword><keyword>health care</keyword><keyword>health services</keyword><keyword>households</keyword><keyword>men</keyword><keyword>poverty</keyword><keyword>questionnaires</keyword><keyword>research workers</keyword><keyword>screening</keyword><keyword>socioeconomic status</keyword><keyword>socioeconomics</keyword><keyword>sociology</keyword><keyword>UN</keyword><keyword>women</keyword></keywords><dates><year>2015</year></dates><pub-location>USA</pub-location><isbn>1932-6203</isbn><urls><related-urls><url>;[57]Physical access to facility??PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FaWRlPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [57, 58]Availability?Services not available??? ADDIN EN.CITE <EndNote><Cite><Author>Eide</Author><Year>2015</Year><RecNum>24</RecNum><DisplayText>[57]</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">24</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eide, A. H.</author><author>Mannan, H.</author><author>Khogali, M.</author><author>Rooy, G. van</author><author>Swartz, L.</author><author>Munthali, A.</author><author>Hem, K. G.</author><author>MacLachlan, M.</author><author>Dyrstad, K.</author></authors></contributors><auth-address>San Francisco</auth-address><titles><title>Perceived barriers for accessing health services among individuals with disability in four African countries</title><secondary-title>PLoS ONE</secondary-title></titles><periodical><full-title>PLoS ONE</full-title></periodical><pages>e0125915</pages><volume>10</volume><number>5</number><keywords><keyword>disabilities</keyword><keyword>education</keyword><keyword>health care</keyword><keyword>health services</keyword><keyword>households</keyword><keyword>men</keyword><keyword>poverty</keyword><keyword>questionnaires</keyword><keyword>research workers</keyword><keyword>screening</keyword><keyword>socioeconomic status</keyword><keyword>socioeconomics</keyword><keyword>sociology</keyword><keyword>UN</keyword><keyword>women</keyword></keywords><dates><year>2015</year></dates><pub-location>USA</pub-location><isbn>1932-6203</isbn><urls><related-urls><url>;[57]Lack of equipment?PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FaWRlPC9BdXRob3I+PFllYXI+MjAxNTwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [17, 57]Difficulty finding doctor? ADDIN EN.CITE <EndNote><Cite><Author>Rahim</Author><Year>2014</Year><RecNum>70</RecNum><DisplayText>[44]</DisplayText><record><rec-number>70</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">70</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rahim, F. S. A.</author><author>Mohamed, A. M.</author><author>Nor, M. M.</author><author>Saub, R.</author></authors></contributors><titles><title>Dental care access among individuals with Down syndrome: a Malaysian scenario</title><secondary-title>Acta Odontologica Scandinavica</secondary-title></titles><periodical><full-title>Acta Odontologica Scandinavica</full-title></periodical><pages>999-1004</pages><volume>72</volume><number>8</number><dates><year>2014</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0001-6357</isbn><accession-num>WOS:000344330400062</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://WOS:000344330400062</url><url>;[44]QualityDiscrimination or lack of awareness amongst health workers?PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CYWR1PC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA [17, 57-59]Previous bad experience?? ADDIN EN.CITE <EndNote><Cite><Author>Eide</Author><Year>2015</Year><RecNum>24</RecNum><DisplayText>[57]</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">24</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eide, A. H.</author><author>Mannan, H.</author><author>Khogali, M.</author><author>Rooy, G. van</author><author>Swartz, L.</author><author>Munthali, A.</author><author>Hem, K. G.</author><author>MacLachlan, M.</author><author>Dyrstad, K.</author></authors></contributors><auth-address>San Francisco</auth-address><titles><title>Perceived barriers for accessing health services among individuals with disability in four African countries</title><secondary-title>PLoS ONE</secondary-title></titles><periodical><full-title>PLoS ONE</full-title></periodical><pages>e0125915</pages><volume>10</volume><number>5</number><keywords><keyword>disabilities</keyword><keyword>education</keyword><keyword>health care</keyword><keyword>health services</keyword><keyword>households</keyword><keyword>men</keyword><keyword>poverty</keyword><keyword>questionnaires</keyword><keyword>research workers</keyword><keyword>screening</keyword><keyword>socioeconomic status</keyword><keyword>socioeconomics</keyword><keyword>sociology</keyword><keyword>UN</keyword><keyword>women</keyword></keywords><dates><year>2015</year></dates><pub-location>USA</pub-location><isbn>1932-6203</isbn><urls><related-urls><url>;[57]Health care providers skills inadequate? ADDIN EN.CITE <EndNote><Cite><Author>World Bank</Author><Year>2011</Year><RecNum>100</RecNum><DisplayText>[17]</DisplayText><record><rec-number>100</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523609163">100</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Bank,</author><author>World Health Organization,</author></authors></contributors><titles><title>The World Report on Disability</title></titles><volume>2018</volume><number>13/04</number><dates><year>2011</year></dates><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>[17] ? ADDIN EN.CITE <EndNote><Cite><Author>Eide</Author><Year>2015</Year><RecNum>24</RecNum><DisplayText>[57]</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">24</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eide, A. H.</author><author>Mannan, H.</author><author>Khogali, M.</author><author>Rooy, G. van</author><author>Swartz, L.</author><author>Munthali, A.</author><author>Hem, K. G.</author><author>MacLachlan, M.</author><author>Dyrstad, K.</author></authors></contributors><auth-address>San Francisco</auth-address><titles><title>Perceived barriers for accessing health services among individuals with disability in four African countries</title><secondary-title>PLoS ONE</secondary-title></titles><periodical><full-title>PLoS ONE</full-title></periodical><pages>e0125915</pages><volume>10</volume><number>5</number><keywords><keyword>disabilities</keyword><keyword>education</keyword><keyword>health care</keyword><keyword>health services</keyword><keyword>households</keyword><keyword>men</keyword><keyword>poverty</keyword><keyword>questionnaires</keyword><keyword>research workers</keyword><keyword>screening</keyword><keyword>socioeconomic status</keyword><keyword>socioeconomics</keyword><keyword>sociology</keyword><keyword>UN</keyword><keyword>women</keyword></keywords><dates><year>2015</year></dates><pub-location>USA</pub-location><isbn>1932-6203</isbn><urls><related-urls><url>;[57]Standard of facility?? ADDIN EN.CITE <EndNote><Cite><Author>Eide</Author><Year>2015</Year><RecNum>24</RecNum><DisplayText>[57]</DisplayText><record><rec-number>24</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">24</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eide, A. H.</author><author>Mannan, H.</author><author>Khogali, M.</author><author>Rooy, G. van</author><author>Swartz, L.</author><author>Munthali, A.</author><author>Hem, K. G.</author><author>MacLachlan, M.</author><author>Dyrstad, K.</author></authors></contributors><auth-address>San Francisco</auth-address><titles><title>Perceived barriers for accessing health services among individuals with disability in four African countries</title><secondary-title>PLoS ONE</secondary-title></titles><periodical><full-title>PLoS ONE</full-title></periodical><pages>e0125915</pages><volume>10</volume><number>5</number><keywords><keyword>disabilities</keyword><keyword>education</keyword><keyword>health care</keyword><keyword>health services</keyword><keyword>households</keyword><keyword>men</keyword><keyword>poverty</keyword><keyword>questionnaires</keyword><keyword>research workers</keyword><keyword>screening</keyword><keyword>socioeconomic status</keyword><keyword>socioeconomics</keyword><keyword>sociology</keyword><keyword>UN</keyword><keyword>women</keyword></keywords><dates><year>2015</year></dates><pub-location>USA</pub-location><isbn>1932-6203</isbn><urls><related-urls><url>;[57]22 studies evaluated barriers to accessing rehabilitation. Commonly reported barriers included, geographic accessibility (distance to service, lack or cost of transport), affordability (of services, treatment, lack of insurance), availability of services, and acceptability-related factors (including perceived need, fear, and lack of awareness about the service) and quality of services. These results are shown in Table 4.Table 4: Quantitative barriers to rehabilitation reported in included studiesReferenceGeographic accessibilityDistance to servicePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmRlcnNzb248L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy

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ADDIN EN.CITE.DATA [61-70] ADDIN EN.CITE <EndNote><Cite><Author>Tan</Author><Year>2015</Year><RecNum>175</RecNum><DisplayText>[71]</DisplayText><record><rec-number>175</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524585917">175</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tan, S. H.</author></authors></contributors><auth-address>University Malaya, Kuala Lumpur, Malaysia tanseokhong@.</auth-address><titles><title>Unmet Health Care Service Needs of Children With Disabilities in Penang, Malaysia</title><secondary-title>Asia Pac J Public Health</secondary-title></titles><periodical><full-title>Asia Pac J Public Health</full-title></periodical><pages>41S-51S</pages><volume>27</volume><number>8 Suppl</number><edition>2015/07/01</edition><keywords><keyword>Caregivers/statistics &amp; numerical data</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>*Disabled Children/statistics &amp; numerical data</keyword><keyword>Female</keyword><keyword>Health Services Accessibility</keyword><keyword>Health Services Needs and Demand/*statistics &amp; numerical data</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Malaysia</keyword><keyword>Male</keyword><keyword>Surveys and Questionnaires</keyword><keyword>access problems</keyword><keyword>children with disabilities</keyword><keyword>health care services</keyword><keyword>needs assessment</keyword><keyword>unmet needs</keyword></keywords><dates><year>2015</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1941-2479 (Electronic)&#xD;1010-5395 (Linking)</isbn><accession-num>26122314</accession-num><urls><related-urls><url>;[71]Transport problemsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmRlcnNzb248L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy

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ADDIN EN.CITE.DATA [56, 60-66, 68, 69, 72-79]Unable to afford treatmentPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGlrb3Zhbmk8L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFy

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ADDIN EN.CITE.DATA [62, 63, 67, 80-82]No insurance ADDIN EN.CITE <EndNote><Cite><Author>Chikovani</Author><Year>2015</Year><RecNum>19</RecNum><DisplayText>[62]</DisplayText><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">19</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chikovani, I.</author><author>Makhashvili, N.</author><author>Gotsadze, G.</author><author>Patel, V.</author><author>McKee, M.</author><author>Uchaneishvili, M.</author><author>Rukhadze, N.</author><author>Roberts, B.</author></authors></contributors><titles><title>Health Service Utilization for Mental, Behavioural and Emotional Problems among Conflict-Affected Population in Georgia: A Cross-Sectional Study</title><secondary-title>Plos One</secondary-title></titles><periodical><full-title>PLoS ONE</full-title></periodical><volume>10</volume><number>4</number><dates><year>2015</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1932-6203</isbn><accession-num>WOS:000352478400076</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://WOS:000352478400076</url><url>;[62]Acceptability?Do not know where to go for treatmentPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmRlcnNzb248L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy

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ADDIN EN.CITE.DATA [61, 62, 64, 65, 67, 69-71, 77, 83]Have not heard about service ADDIN EN.CITE <EndNote><Cite><Author>Udeh</Author><Year>2014</Year><RecNum>84</RecNum><DisplayText>[82]</DisplayText><record><rec-number>84</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">84</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Udeh, N. N.</author><author>Eze, B. I.</author><author>Onwubiko, S. N.</author><author>Arinze, O. C.</author><author>Onwasigwe, E. N.</author><author>Umeh, R. E.</author></authors></contributors><auth-address>New York</auth-address><titles><title>Oculocutaneous albinism: identifying and overcoming barriers to vision care in a Nigerian population</title><secondary-title>Journal of Community Health</secondary-title></titles><periodical><full-title>Journal of Community Health</full-title></periodical><pages>508-513</pages><volume>39</volume><number>3</number><keywords><keyword>albinism</keyword><keyword>complications</keyword><keyword>eye diseases</keyword><keyword>eyes</keyword><keyword>health care</keyword><keyword>health care utilization</keyword><keyword>health services</keyword><keyword>human diseases</keyword><keyword>social barriers</keyword><keyword>vision disorders</keyword></keywords><dates><year>2014</year></dates><pub-location>USA</pub-location><isbn>0094-5145</isbn><urls><related-urls><url>;[82]Thought nothing could be donePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmRlcnNzb248L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy

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ADDIN EN.CITE.DATA [57, 61]Family do not perceive need ADDIN EN.CITE <EndNote><Cite><Author>Kovai</Author><Year>2007</Year><RecNum>40</RecNum><DisplayText>[64]</DisplayText><record><rec-number>40</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">40</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kovai, Vilas</author><author>Krishnaiah, Sannapaneni</author><author>Shamanna, B. R.</author><author>Ravi, T.</author><author>Rao, G. N.</author></authors></contributors><auth-address>Mumbai</auth-address><titles><title>Barriers to accessing eye care services among visually impaired populations in rural Andhra Pradesh, South India</title><secondary-title>Indian Journal of Ophthalmology</secondary-title></titles><periodical><full-title>Indian Journal of Ophthalmology</full-title></periodical><pages>365-372</pages><volume>55</volume><number>5</number><keywords><keyword>eyes</keyword><keyword>health care</keyword><keyword>health care costs</keyword><keyword>health services</keyword><keyword>human diseases</keyword><keyword>knowledge level</keyword><keyword>people with visual impairment</keyword><keyword>rural areas</keyword><keyword>socioeconomic status</keyword><keyword>vision</keyword><keyword>vision disorders</keyword></keywords><dates><year>2007</year></dates><pub-location>India</pub-location><isbn>0301-4738</isbn><urls><related-urls><url>;[64]Fear of seeking carePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmRlcnNzb248L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy

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ADDIN EN.CITE.DATA [62, 64, 65, 67, 69-71, 73, 80]Other medical problems ADDIN EN.CITE <EndNote><Cite><Author>Kovai</Author><Year>2007</Year><RecNum>40</RecNum><DisplayText>[64]</DisplayText><record><rec-number>40</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">40</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kovai, Vilas</author><author>Krishnaiah, Sannapaneni</author><author>Shamanna, B. R.</author><author>Ravi, T.</author><author>Rao, G. N.</author></authors></contributors><auth-address>Mumbai</auth-address><titles><title>Barriers to accessing eye care services among visually impaired populations in rural Andhra Pradesh, South India</title><secondary-title>Indian Journal of Ophthalmology</secondary-title></titles><periodical><full-title>Indian Journal of Ophthalmology</full-title></periodical><pages>365-372</pages><volume>55</volume><number>5</number><keywords><keyword>eyes</keyword><keyword>health care</keyword><keyword>health care costs</keyword><keyword>health services</keyword><keyword>human diseases</keyword><keyword>knowledge level</keyword><keyword>people with visual impairment</keyword><keyword>rural areas</keyword><keyword>socioeconomic status</keyword><keyword>vision</keyword><keyword>vision disorders</keyword></keywords><dates><year>2007</year></dates><pub-location>India</pub-location><isbn>0301-4738</isbn><urls><related-urls><url>;[64] ADDIN EN.CITE <EndNote><Cite><Author>Gadallah</Author><Year>2015</Year><RecNum>32</RecNum><DisplayText>[81]</DisplayText><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">32</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gadallah, M. A.</author><author>Boulos, D. N. K.</author><author>Gebrel, A.</author><author>Dewedar, S.</author><author>Morisky, D. E.</author></authors></contributors><titles><title>Assessment of Rheumatoid Arthritis Patients&apos; Adherence to Treatment</title><secondary-title>American Journal of the Medical Sciences</secondary-title></titles><periodical><full-title>American Journal of the Medical Sciences</full-title></periodical><pages>151-156</pages><volume>349</volume><number>2</number><dates><year>2015</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0002-9629</isbn><accession-num>WOS:000349353900009</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://WOS:000349353900009</url><url>;[81]ShamePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmRlcnNzb248L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy

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ADDIN EN.CITE.DATA [57, 61]I did not trust that the health care staff would keep my problem confidential ADDIN EN.CITE <EndNote><Cite><Author>Andersson</Author><Year>2013</Year><RecNum>9</RecNum><DisplayText>[61]</DisplayText><record><rec-number>9</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">9</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Andersson, L. M. C.</author><author>Schierenbeck, I.</author><author>Strumpher, J.</author><author>Krantz, G.</author><author>Topper, K.</author><author>Backman, G.</author><author>Ricks, E.</author><author>Van Rooyen, D.</author></authors></contributors><titles><title>Help-seeking behaviour, barriers to care and experiences of care among persons with depression in Eastern Cape, South Africa</title><secondary-title>Journal of Affective Disorders</secondary-title></titles><periodical><full-title>Journal of Affective Disorders</full-title></periodical><pages>439-448</pages><volume>151</volume><number>2</number><dates><year>2013</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0165-0327</isbn><accession-num>WOS:000325432900005</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://WOS:000325432900005</url><url>(13)00502-8/pdf</url></related-urls></urls><electronic-resource-num>10.1016/j.jad.2013.06.022</electronic-resource-num></record></Cite></EndNote>[61]Availability ?Waiting time at the clinicPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbmRlcnNzb248L0F1dGhvcj48WWVhcj4yMDEzPC9ZZWFy

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ADDIN EN.CITE.DATA [70]Poor relationship with provider ADDIN EN.CITE <EndNote><Cite><Author>Fletcher</Author><Year>1999</Year><RecNum>29</RecNum><DisplayText>[80]</DisplayText><record><rec-number>29</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1523608219">29</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Fletcher, A. E.</author><author>Donoghue, M.</author><author>Devavaram, J.</author><author>Thulasiraj, R. D.</author><author>Scott, S.</author><author>Abdalla, M.</author><author>Shanmugham, C. A. K.</author><author>Murugan, P. B.</author></authors></contributors><auth-address>A.E. Fletcher, Dept. of Epidemiol./Population Hlth., London Sch. of Hygiene/Tropical Med., London WC1E 7HT, United Kingdom. E-mail: a.fletcher@lshtm.ac.uk</auth-address><titles><title>Low uptake of eye services in rural India: A challenge for programs of blindness prevention</title><secondary-title>Archives of Ophthalmology</secondary-title></titles><periodical><full-title>Archives of Ophthalmology</full-title></periodical><pages>1393-1399</pages><volume>117</volume><number>10</number><keywords><keyword>adult</keyword><keyword>article</keyword><keyword>*blindness/pc [Prevention]</keyword><keyword>cataract extraction</keyword><keyword>cost</keyword><keyword>female</keyword><keyword>*health care utilization</keyword><keyword>*health program</keyword><keyword>human</keyword><keyword>India</keyword><keyword>major clinical study</keyword><keyword>male</keyword><keyword>priority journal</keyword><keyword>visual acuity</keyword></keywords><dates><year>1999</year></dates><pub-location>United States</pub-location><publisher>American Medical Association (515 North State Street, Chicago IL 60654, United States)</publisher><isbn>0003-9950</isbn><urls><related-urls><url>;[80] PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Lb3ZhaTwvQXV0aG9yPjxZZWFyPjIwMDc8L1llYXI+PFJl

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ADDIN EN.CITE.DATA [78] ADDIN EN.CITE <EndNote><Cite><Author>Tan</Author><Year>2015</Year><RecNum>175</RecNum><DisplayText>[71]</DisplayText><record><rec-number>175</rec-number><foreign-keys><key app="EN" db-id="ft0e9z9f4x25x5e9wxqx5t9pt9s5zzxrsdvs" timestamp="1524585917">175</key><key app="ENWeb" db-id="">0</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tan, S. H.</author></authors></contributors><auth-address>University Malaya, Kuala Lumpur, Malaysia tanseokhong@.</auth-address><titles><title>Unmet Health Care Service Needs of Children With Disabilities in Penang, Malaysia</title><secondary-title>Asia Pac J Public Health</secondary-title></titles><periodical><full-title>Asia Pac J Public Health</full-title></periodical><pages>41S-51S</pages><volume>27</volume><number>8 Suppl</number><edition>2015/07/01</edition><keywords><keyword>Caregivers/statistics &amp; numerical data</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>*Disabled Children/statistics &amp; numerical data</keyword><keyword>Female</keyword><keyword>Health Services Accessibility</keyword><keyword>Health Services Needs and Demand/*statistics &amp; numerical data</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Malaysia</keyword><keyword>Male</keyword><keyword>Surveys and Questionnaires</keyword><keyword>access problems</keyword><keyword>children with disabilities</keyword><keyword>health care services</keyword><keyword>needs assessment</keyword><keyword>unmet needs</keyword></keywords><dates><year>2015</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1941-2479 (Electronic)&#xD;1010-5395 (Linking)</isbn><accession-num>26122314</accession-num><urls><related-urls><url>;[71]The review identified some particular barriers to which people with disabilities may be particularly vulnerable, including discrimination from the health provider, provider lacking skills, and communication barriers. However other barriers like cost and distance may be experienced among both disabled and non-disabled populations. It is questionable whether barriers can be assessed through quantitative questionnaires, as included in this review. The reasons why people choose to attend healthcare services, or not, are complex and inter-related and often cannot be reduced to simple answers. People may say that cost is the main barrier, whereas in fact this may mean that not enough priority within the family is given to the person with disability to support spending money, so that discrimination and neglect is the true barrier. As an example of the difficulties in measuring barriers, a study was undertaken on cataract in Kenya, the Philippines and Bangladesh.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TeWVkPC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48UmVj

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