Introduction - International Disability Alliance



2221230-45407400At risk of exclusion from CRPD and SDGs implementation:Inequality and Persons with DeafblindnessInitial global report on situation and rights of persons with deafblindnessSeptember 2018Representing between 0.2% to 2% of the population, persons with deafblindness are a very diverse yet hidden group and are, overall, more likely to be poor and unemployed, and with lower educational outcomes. Because deafblindness is less well-known and often misunderstood, people struggle to obtain the right support, and are often excluded from both development and disability programmes.This initial global report on the situation of persons with deafblindness seeks to start a dialogue between international disability rights and development stakeholders, and is based on research undertaken by the World Federation of the Deafblind (WFDB) combining the largest population-based analysis of persons with deafblindness conducted to date (disaggregation of 22 population-based surveys from low, middle and high-income countries), an academic literature review, two surveys conducted among members and partners of WFDB and Sense International.Women and men with deafblindness from across the world took part in the Helen Keller World Conference in June 2018, and were consulted to confirm the findings and elaborate on the recommendations for this report. Table of contents TOC \o "1-3" \h \z \u Introduction PAGEREF _Toc524071174 \h 2The diversity of persons with deafblindness PAGEREF _Toc524071175 \h 3Overview of international obligations under the CRPD PAGEREF _Toc524071176 \h 6Key precondition for inclusion: recognition of deafblindness and the provision of specific support services PAGEREF _Toc524071177 \h 7Persons with deafblindness and inequality PAGEREF _Toc524071178 \h 14Methodology PAGEREF _Toc524071179 \h 14Review of the literature PAGEREF _Toc524071180 \h 14Country data analyses PAGEREF _Toc524071181 \h 14WFDB and Sense International member and partner surveys PAGEREF _Toc524071182 \h 15The challenges of ‘counting’ persons with deafblindness PAGEREF _Toc524071183 \h 15Persons with deafblindness and poverty PAGEREF _Toc524071184 \h 18Persons with deafblindness and work PAGEREF _Toc524071185 \h 21Persons with deafblindness and education PAGEREF _Toc524071186 \h 26Persons with deafblindness and health PAGEREF _Toc524071187 \h 32Persons with deafblindness and participation in political and public life PAGEREF _Toc524071188 \h 36Persons with deafblindness and social life PAGEREF _Toc524071189 \h 40The long read: Being a woman and mother with deafblindness PAGEREF _Toc524071190 \h 44Conclusion and recommendations PAGEREF _Toc524071191 \h 48References PAGEREF _Toc524071192 \h 52Annex 1 PAGEREF _Toc524071193 \h 54Detailed data tables PAGEREF _Toc524071194 \h 57Acknowledgement and disclaimers PAGEREF _Toc524071195 \h 64Introduction Echoing the changes triggered by the UN Convention on the Rights of Persons with Disabilities (CRPD), the adoption of Agenda 2030 and the Sustainable Development Goals (SDGs) emphasised the importance of inclusive development and leaving no one behind. Worldwide, there is a growing momentum for change based on inclusion, which marks a significant shift from the invisibility and exclusion of persons with disabilities from the Millennium Development Goals (MDGs). However, it is vital to recognise that persons with disabilities are not a homogenous group, and some constituencies, such as persons with deafblindness, remain marginalised and, in many ways, invisible. Persons with deafblindness represent between 0.2% and 2% of the global population and are more likely to live in poverty and be unemployed, with lower educational outcomes than other persons with disabilities. They face multiple barriers, such as a lack of access to support services and accessible information, which ultimately makes it extremely difficult to voice their issues.In many countries, persons with deafblindness are not recognised as a distinct disability group. This has contributed to a persistent statistical invisibility even when efforts are made by governments to collect disability-related data. This is reflected at international level, with only seven references to persons with deafblindness in the 2011 landmark World Report on Disability ADDIN EN.CITE <EndNote><Cite><Author>World Health Organization &amp; World Bank</Author><Year>2011</Year><RecNum>4</RecNum><DisplayText>[1]</DisplayText><record><rec-number>4</rec-number><foreign-keys><key app="EN" db-id="wz5eaf5a0st2s6e2pec55fs0z9dvftws5pre" timestamp="0">4</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>World Health Organization &amp; World Bank,</author></authors></contributors><titles><title>World report on disability</title></titles><dates><year>2011</year></dates><publisher>World Health Organization</publisher><isbn>9241564180</isbn><urls></urls></record></Cite></EndNote>[1]. The experiences of the World Federation of the Deafblind (WFDB), Sense International (SI) and the International Disability Alliance (IDA) in the last 10 years indicate that the issues faced by persons with deafblindness have largely been ignored.Evidence confirms a disability and development gap ADDIN EN.CITE <EndNote><Cite><Author>Groce</Author><Year>2013</Year><RecNum>154</RecNum><DisplayText>[2]</DisplayText><record><rec-number>154</rec-number><foreign-keys><key app="EN" db-id="wz5eaf5a0st2s6e2pec55fs0z9dvftws5pre" timestamp="1528129530">154</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Groce, N.</author><author>Kett, Maria</author></authors></contributors><titles><title>The Disability and Development Gap</title><secondary-title>Leonard Cheshire Working Paper Series</secondary-title></titles><dates><year>2013</year></dates><pub-location>London</pub-location><publisher>Leonard Cheshire Disability and Inclusive Development Centre</publisher><urls></urls></record></Cite></EndNote>[2], and there is a significant risk that efforts to implement the CRPD and inclusive SDGs will exclude persons with deafblindness, among other marginalised groups. WFDB and SI agree that the relative invisibility of persons with deafblindness is both a cause and a consequence of a lack of understanding across disability rights and development stakeholders, both in terms of the extent and diversity of their issues, as well as their specific inclusion requirements.A literature review conducted for this report found that there is a lack of good quality, comparable data on persons with deafblindness. The majority of studies documented were small in scale and focused only on people in specific circumstances, such as members of deafblind organisations, people in assisted living, and those who attend rehabilitation centres. The review also found that most research focused on adults who acquired deafblindness later in life or was undertaken in the United States or European countries. There were almost no studies from low or middle-income countries.This initial global report has, therefore, been conceived as an evidence-based awareness raising tool, as well as to contribute to the global monitoring of both CRPD and the SDGs. It will feed into the 2020 SDG baseline and will be followed by monitoring reports in 2022, 2026 and bining the largest population-based analysis of persons with deafblindness conducted to date (disaggregation of 22 population-based surveys from low, middle and high-income countries), an academic literature review, two surveys conducted among members and partners of WFDB and Sense International, and case studies, the report covers the diversity of persons with deafblindness, their lived experiences, and the barriers and inequalities they face. It also seeks to develop concrete recommendations for member states, development agencies and civil society organisations.The findings of this report were presented at the 2018 Helen Keller World Conference. Women and men with deafblindness from across the world shared their experiences and elaborated on the recommendations for the report. The diversity of persons with deafblindness Deafblindness is often underestimated and misunderstood, and this contributes significantly to the many barriers faced by persons with deafblindness. Some persons with deafblindness are completely deaf and blind, but many have a little sight and/or hearing they can use. Based on the Nordic definition ADDIN EN.CITE <EndNote><Cite><Author>The Deafblind Nordic Cooperation Committee</Author><Year>n.d.</Year><RecNum>155</RecNum><DisplayText>[3]</DisplayText><record><rec-number>155</rec-number><foreign-keys><key app="EN" db-id="wz5eaf5a0st2s6e2pec55fs0z9dvftws5pre" timestamp="1528131171">155</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>The Deafblind Nordic Cooperation Committee,</author></authors></contributors><titles><title>The Nordic definition of deafblindness</title></titles><volume>2018</volume><number>June 2</number><dates><year>n.d.</year></dates><urls><related-urls><url>;[3], the WFDB defines deafblindness as a distinct disability arising from a dual sensory impairment of a severity that makes it hard for the impaired senses to compensate for each other. In interaction with barriers in the environment, it affects social life, communication, access to information, orientation and mobility. Enabling inclusion and participation requires accessibility measures and access to specific support services, such as interpreter-guides, among others.The age of onset of a person’s vision and hearing impairment has a profound impact on the consequences of deafblindness, particularly in relation to communicative development and language acquisition. It is therefore important to differentiate.Pre-lingual deafblindness,?which describes a vision and hearing impairment acquired at birth or at an early stage in life before the development of language. This may be due to infections during pregnancy, premature birth, birth trauma or genetic conditions (e.g. Down’s syndrome, Usher syndrome and CHARGE).Post-lingual deafblindness,?which describes vision and hearing loss acquired following the development of language (spoken or sign language). Deafblindness can be caused by illness, accident or as a result of age-related conditions associated with the loss of vision and hearing (e.g. cataracts, glaucoma and macular degeneration for vision loss, and presbycusis for hearing loss) ADDIN EN.CITE <EndNote><Cite><Author>Dammeyer</Author><Year>2013</Year><RecNum>62</RecNum><DisplayText>[4, 5]</DisplayText><record><rec-number>62</rec-number><foreign-keys><key app="EN" db-id="52wvpr59hpwzwfestwr5ewtvpawz0pssr5t9" timestamp="1512405585">62</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dammeyer, Jesper</author></authors></contributors><titles><title>Characteristics of a Danish population of adults with acquired deafblindness receiving rehabilitation services</title><secondary-title>British Journal of Visual Impairment</secondary-title></titles><periodical><full-title>British Journal of Visual Impairment</full-title></periodical><pages>189-197</pages><volume>31</volume><number>3</number><dates><year>2013</year></dates><isbn>0264-6196</isbn><urls></urls></record></Cite><Cite><Author>Klaver</Author><Year>1998</Year><RecNum>63</RecNum><record><rec-number>63</rec-number><foreign-keys><key app="EN" db-id="52wvpr59hpwzwfestwr5ewtvpawz0pssr5t9" timestamp="1512406051">63</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Klaver, Caroline CW</author><author>Wolfs, Roger CW</author><author>Vingerling, Johannes R</author><author>Hofman, Albert</author><author>de Jong, Paulus TVM</author></authors></contributors><titles><title>Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study</title><secondary-title>Archives of ophthalmology</secondary-title></titles><periodical><full-title>Archives of Ophthalmology</full-title></periodical><pages>653-658</pages><volume>116</volume><number>5</number><dates><year>1998</year></dates><isbn>0003-9950</isbn><urls></urls></record></Cite></EndNote>[4, 5]. While Usher syndrome is an inherited genetic condition, it typically manifests itself (visual and/or hearing loss ) in later childhood or adolescence, following the development of language ADDIN EN.CITE <EndNote><Cite><Author>Wolsey</Author><Year>2017</Year><RecNum>57</RecNum><DisplayText>[6]</DisplayText><record><rec-number>57</rec-number><foreign-keys><key app="EN" db-id="52wvpr59hpwzwfestwr5ewtvpawz0pssr5t9" timestamp="1512400387">57</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wolsey, Ju-Lee A</author></authors></contributors><titles><title>Perspectives and Experiences of DeafBlind College Students</title><secondary-title>The Qualitative Report</secondary-title></titles><periodical><full-title>The Qualitative Report</full-title></periodical><pages>2066</pages><volume>22</volume><number>8</number><dates><year>2017</year></dates><isbn>1052-0147</isbn><urls></urls></record></Cite></EndNote>[6].Deafblindness is more prevalent among older age groups. However, among children and young adults, deafblindness presents additional implications, impacting on learning and gaining employment.A diversity of barriers and a diversity of support requirements “For me personally, in some optimal times when the light is perfect and the noise level low, I can manage pretty good myself. But when, for example, I go into the centre of our city and the sun shines strongly then I can?t see at all and, as it is often very noisy all around, I can?t hear what is being said to me and it is very difficult to manage myself. But I'm not deafblind because in other situations I can see and hear better. It is therefore much easier to identify myself with the term ‘person with deafblindness’.” C. Nilsson, SwedenEach person with deafblindness connects, communicates and experiences the world differently. Each individual may face restrictions of participation that are affected by the level of support and barriers in their environment, the severity of the vision and hearing impairment, and the age of onset, among other elements. Persons with deafblindness constitute a diversified group with a broad experience of disability and may have different support and inclusion requirements. It is vital, therefore, that persons with deafblindness access services that meet each individual’s needs and not a combination of services designed for blind or deaf people. While persons with deafblindness may require support to access information, communicate, interact and move freely on an equal basis with others, the type and level of support varies from individual to individual.Some persons with deafblindness may experience other functional difficulties and therefore may have additional support needs.Persons with deafblindness frequently require support for: CommunicationThere is a variety of techniques and methods of communication support, and there is no standard way of communicating. Communication approaches are likely to vary based on whether a person has pre-lingual or post-lingual deafblindness, which impairment developed first, and the level of residual hearing or sight ADDIN EN.CITE <EndNote><Cite><Author>Simcock</Author><Year>2017</Year><RecNum>6</RecNum><DisplayText>[7]</DisplayText><record><rec-number>6</rec-number><foreign-keys><key app="EN" db-id="r9s0stzxi0wt9pepwey55fzeat5ve5v95srs" timestamp="1528129166">6</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Simcock, Peter</author></authors></contributors><titles><title>One of society&apos;s most vulnerable groups? A systematically conducted literature review exploring the vulnerability of deafblind people</title><secondary-title>Health &amp; social care in the community</secondary-title></titles><pages>813-839</pages><volume>25</volume><number>3</number><dates><year>2017</year></dates><isbn>1365-2524</isbn><urls></urls></record></Cite></EndNote>[7]. For example, people with profound hearing impairments who later develop a visual impairment may still be able to communicate with sign language, with some adaptations. Similarly, people with profound vision impairments who develop hearing impairments may have benefited from braille instruction, but may now require clear speech interpreting. People with pre-lingual deafblindness will use different approaches to acquire language. A wide range of communication methods ADDIN EN.CITE <EndNote><Cite><Author>World Federation of the Deafblind</Author><Year>2018</Year><RecNum>156</RecNum><DisplayText>[8]</DisplayText><record><rec-number>156</rec-number><foreign-keys><key app="EN" db-id="wz5eaf5a0st2s6e2pec55fs0z9dvftws5pre" timestamp="1528137877">156</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Federation of the Deafblind,</author></authors></contributors><titles><title>Deafblind Interpretation</title></titles><volume>2018</volume><number>June 2</number><dates><year>2018</year></dates><urls><related-urls><url>;[8] exist, including:Tactile interpreting (i.e. tactile sign language to one person with deafblindness) or finger spelling of the manual alphabet.Close vision interpreting (i.e. visual sign language within close proximity to a person with deafblindness) or visual frame interpreting (i.e. visual sign language to more than one person with deafblindness).Clear speech interpreting (with or without hearing aids) or speech-to-text interpreting (with certain adaptions and with or without technical equipment, such as a computers, large screens and braille displays).Depending on the person and the situation, any one and/or combination of methods may be required. Furthermore, communication strategies may change over time, particularly if the individual experiences changes in the severity of their hearing and/or visual impairments ADDIN EN.CITE <EndNote><Cite><Author>Simcock</Author><Year>2017</Year><RecNum>56</RecNum><DisplayText>[9]</DisplayText><record><rec-number>56</rec-number><foreign-keys><key app="EN" db-id="52wvpr59hpwzwfestwr5ewtvpawz0pssr5t9" timestamp="1512398400">56</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Simcock, Peter</author></authors></contributors><titles><title>Ageing with a unique impairment: a systematically conducted review of older deafblind people&apos;s experiences</title><secondary-title>Ageing &amp; Society</secondary-title></titles><periodical><full-title>Ageing &amp; Society</full-title></periodical><pages>1703-1742</pages><volume>37</volume><number>8</number><dates><year>2017</year></dates><isbn>0144-686X</isbn><urls></urls></record></Cite></EndNote>[9].Persons with deafblindness may also use assistive technology to support communication. Examples of assistive products include braille displays and writers, hearing aids and loops, and glasses and/or magnifiers. However, it is important to remember that such assistive products will not meet every individual’s needs in all circumstances, and that support may be required in other areas, such as that provided by an interpreter-guide. Mobility The ability to get around fully and freely is essential to full and effective inclusion and equal participation. For some persons with deafblindness, qualified guiding to support mobility and orientation may be necessary. Guiding is also considered an integral part of interpreter-guide services, as it is not possible to guide and describe for a person with deafblindness without being able to communicate.DescriptionIn order to fully understand and connect with the environment, some persons with deafblindness choose to use description. This not only encompasses physical surroundings, such as walls and windows, but also occurrences, people and physical objects, including books, posters, and both digital and printed brochures.The WFDB considers description an integral part of any interpreter-guide service. It should be offered at the same time as guiding and interpreting of speech, according to the situation ADDIN EN.CITE <EndNote><Cite><Author>World Federation of the Deafblind</Author><Year>2018</Year><RecNum>156</RecNum><DisplayText>[8]</DisplayText><record><rec-number>156</rec-number><foreign-keys><key app="EN" db-id="wz5eaf5a0st2s6e2pec55fs0z9dvftws5pre" timestamp="1528137877">156</key></foreign-keys><ref-type name="Web Page">12</ref-type><contributors><authors><author>World Federation of the Deafblind,</author></authors></contributors><titles><title>Deafblind Interpretation</title></titles><volume>2018</volume><number>June 2</number><dates><year>2018</year></dates><urls><related-urls><url>;[8].The critical importance of an interpreter-guide While some persons with deafblindness may use communication or basic mobility support in a familiar environment, most will require support from an interpreter-guide in other situations, depending on the circumstances. Interpreter-guide services are truly responsive to the compounded support requirements of persons with deafblindness, both in terms of communication and mobility. The service offers support in line with article 19 of the CRPD, allowing persons with deafblindness to live autonomously and be included in the community. A professional interpreter-guide service can be the key to accessing other services and fundamental rights, such as education, employment, healthcare, culture and recreation. A diversity of support services (non-exhaustive list)Mobility and communicationInterpreter-guide A professional who provides communication and mobility support, including guiding and description, which is adapted to the needs of the person. Proper and appropriate communication methods are used at any given time and munication Tactile communication Tactile sign language: a common means of communication used by persons with deafblindness. Signs are primarily indicated in the palm of the hand.3077845000Tactile fingerspelling: a variation of tactile sign language using finger-based signs that follow a specific pattern.3072130000Tactile alphabet: communication based on spelling words, letter by letter, and indicating block letters in the palm of the hand of the individual.TadomaCommunication through jaw movements, vibrations and the facial expressions of the speaker, achieved by placing a thumb on the speaker’s lips and the remaining fingers along the face and neck.Visual frame interpretingSign language that is adapted to fit a limited field of vision with a person who has some degree of residual sight.Clear speechAn effective and commonly used method of communication for people who have some degree of residual hearing.Braille/moonBraille is a system that uses a series of raised dots (six in two columns of three) to represent letters or groups of letters.Moon is similar to braille but uses raised, adapted capital letters that are simpler to feel.Assistive devicesHearingHearing aid: a small electronic device that is placed behind or inside the ear to amplify sound and speech. Essential in combination with clear speech interpretation.Cochlear implant (CI): a surgically implanted electronic device that provides a sense of sound, bypassing the hearing process that has been impaired.Loop: a unique sound system used by people with hearing aids. The hearing loop?provides a magnetic, wireless signal that is picked up by the hearing aid and/or cochlear implants.Reading/writingBraille reader/display: a device enabling one and/or two-way communication through computers, smartphones and similar devices using braille. MobilityRed and white striped cane: identifies a person as having a combined sight and hearing impairment.Overview of international obligations under the CRPD The CRPD applies to all persons with disabilities without distinction and all human rights standards apply to all persons with disabilities. The diversity of persons with disabilities (and their diverse inclusion requirements) is recognised and serves as a core principle. The CRPD also acknowledges the imperative to promote and protect the rights of persons with disabilities who require more intensive support, which is likely to apply to persons with deafblindness. Persons with disabilities should not be excluded or discriminated against because of the nature of their disability.Deafblindness is specifically mentioned in the CRPD under article 24 (Education) and has been recognised by the Committee in several General Comments and Concluding Observations. Based on this recognition in international law, as well as the recognition of deafblindness as a distinct disability in the legislation of many countries, states have an obligation to acknowledge and respond to the requirements of persons with deafblindness across legislation, policy, programmes and budgets. The CRPD recognises a wide range of communication methods, such as tactile communication and braille, and languages, including sign languages and non-spoken languages, which may be used by persons with deafblindness. The General Comment No. 2 on Article 9: Accessibility of the Committee on Rights of Persons with Disabilities (CRPD/C/GC/2) provides further clarity on states’ obligations to enable persons with deafblindness to access information, communication and other services in order to live independently and to effectively participate in society. States, therefore, must address key issues, such as a lack of adequate communication training among service providers. In addition, they must provide live assistance and intermediaries, such as guides and interpreters, to remove barriers to communication, information and other services. States must also ensure a minimum quality of communication-related services, such as interpretation and personal assistance, and aim for standardisation across the board. Accessibility is not limited to communication and information. Persons with deafblindness experience many barriers to orientation and mobility in public spaces. Therefore, states should provide access to signage in braille or live assistance and intermediaries, such as interpreter-guides, to facilitate accessibility and mobility. Crucially, states must establish minimum standards in terms of the accessibility of services provided by public and private entities. This will improve general access for persons with deafblindness across different sectors, such as work, education and health.Reasonable accommodations may also improve access for persons with deafblindness, particularly where accessibility standards are not implemented or if a person’s requirements fall outside the scope of such standards. For persons with deafblindness, reasonable accommodations often include communication, orientation and mobility support, either through the use of aids, assistive devices and/or live assistance, such as interpreter-guides. Importantly, reasonable accommodation may also include the adaptation of work schedules or procedures, among other changes.For the purpose of this report, two key proxy indicators were identified to assess whether states have taken the appropriate steps to implement the CRPD provisions for persons with deafblindness. These indicators are: the official recognition of persons with deafblindness as a distinct disability group and the provision of interpreter-guide services. Key precondition for inclusion: recognition of deafblindness and the provision of specific support services To participate and be included in community, work, education or political life, persons with deafblindness require both the removal of environmental barriers as well as those that prevent access to quality support services. Accessibility features for persons with deafblindness include a wide range of passive accessibility elements related to the built, informational and communicational environment. These features are also common to other persons with disabilities, such as documents being accessible in braille, captioning, tactile patterns on floors, contrasted colours in facilities, loop systems and accessible websites.However, due to the specific functional restrictions caused by deafblindness, such accessibility features are often insufficient and individual support is required. Through the survey and exchanges at the 2018 Helen Keller World Conference, WFDB members highlighted the lack of awareness and recognition of deafblindness. Indeed, many governments mistakenly assume that services for deaf or blind people are sufficient for persons with deafblindness. Due to the fact that accessibility issues are widely known, this report focuses on two key asks from WFDB members: official recognition of deafblindness and the provision of specific support services. Official recognition of persons with deafblindness One of the fundamental demands of WFDB and its members is the recognition of deafblindness by states, as well as other international, national and sub-national actors, as a distinct disability. In many countries, the absence of such recognition leads to invisibility in statistics, policies, programmes and services, both for the general population and for persons with disabilities. In addition, it contributes to the lack of attention paid to the specific support required by persons with deafblindness across all sectors, perpetuating their exclusion.In 2017, WFDB and SI surveyed their members about the official recognition of deafblindness and available support in their country. From the 50 countries for which data was available, 19 (37%) officially recognise deafblindness as a distinct disability. The survey also indicated that countries that do officially recognise deafblindness as a distinct disability and/or have a definition of deafblindness are more likely to provide specific support services. This is particularly the case in low and middle-income countries. 0-24%; 25-49%50-74%; 75-100%High-income countries (N=19)Upper-middle income countries (N=13)Lower-middle and low-income countries (N=18)ALL(N=50)Is 'deafblindness' recognised as a unique disability in your country?32%38%44%37%Is there an official definition of deafblindness in your country?37%62%44%46%The vicious circle: a lack of awareness and a lack of recognition The majority of WFDB members consulted highlighted the need for greater visibility of deafblindness. Members also suggested the need to raise societal awareness of persons with deafblindness and their communication requirements so that steps can be taken to make society more inclusive.A vicious circle was identified in relation to the non-recognition of deafblindness whereby a lack of understanding about the diversity and issues faced by persons with deafblindness contributes to a lack of recognition of deafblindness as a unique disability. This, in turn, reinforces their invisibility, lack of awareness and access to support. “People always think that persons with deafblindness are ‘totally deaf and totally blind’ and we always have to explain! People don't accept that a person cannot have ‘only’ a combination of both hearing and vision impairment, which creates a unique situation.” (participant at 2018 HKWC consultation)It was also reported that health and rehabilitation professionals lack an understanding of the situation of persons with deafblindness. For example, professionals often consider people that are not fully deaf and blind as either a deaf person with a visual impairment or a blind person with a hearing impairment. This leads to persons with deafblindness being underestimated and limits the development of adequate support services that are truly responsive to each individual’s specific needs. In many countries, deafblindness is not considered a standalone disability, and as a result persons with deafblindness are qualified as having multiple disabilities. Some countries, including India through its recent disability rights legislation, acknowledge deafblindness but include it within a multiple disabilities category, thus potentially limiting the positive effect of legal recognition on the development of support services and resource allocation. Several WFDB members mentioned that, because deafblindness is not recognised in their country, individuals have to select either deaf or blind on official forms and documents, which leads to invisibility in statistical or administrative data. In the EU, as of 2014, only three of the 27 states were collecting official census data regarding the number of persons with deafblindness. ?In disability and eligibility determination, a lack of recognition leads to people receiving two separate disability and/or medical certificates. This creates an additional administrative burden and cost for persons with deafblindness and their families. Where data is available, governments consider persons with deafblindness as a small group that require only the minimum allocation of resources. Again, a lack of understanding about the diversity and extent of communication and support required leads to a significant underestimation of the resources needed to provide appropriate levels of support. “The government does not support activities or projects for persons with deafblindness because, as it is a small number of people, it cannot show a huge social impact and achieve a significant political return.” (participant at 2018 HKWC consultation) One recurrent issue is the non-recognition of persons with deafblindness within the disability movement. Whilst there has been progress in recent years, it is still a challenge for organisations of persons with deafblindness to secure adequate resources in many countries, both rich and poor. Once again, a lack of official recognition deprives organisations of persons with deafblindness the necessary resources to carry out much-needed awareness raising and advocacy work. Recommendations For national governments:Recognise deafblindness as a unique disability in law and practice.Raise awareness about the specific situation and requirements of persons with deafblindness. Collect and analyse data about the experiences, barriers and support requirements of persons with deafblindness. Recognise the specificity of communication systems used by persons with deafblindness. Include deafblindness as a specific disability group and facilitate eligibility determination procedures.Support organisations of persons with deafblindness to carry out outreach, awareness raising and advocacy. For DPOs:Recognise and include organisations of persons with deafblindness as distinct and integral members of the disability movement. Support the official recognition of deafblindness as a unique disability in law and practice.Raise the awareness of member states regarding their obligations towards persons with deafblindness under the CRPD.For the UN and development agencies: Universal recognition of deafblindness as a unique and distinct disability, including in international classifications.Collect and analyse data about the experiences, barriers and support requirements of persons with deafblindness. Raise the awareness of member states regarding their obligations towards persons with deafblindness under the CRPD.Support the official recognition by member states of deafblindness as a unique disability in law and practice.Support organisations of persons with deafblindness to carry out outreach, awareness raising and advocacy work. Ongoing efforts: From laws to enforceable regulation – the long advocacy road towards recognition and the development of interpreter-guide service. Sense International, PeruIn 2010, the Peruvian authorities passed two key laws. Law 29524 recognised deafblindness as a unique disability and Law 29535 recognised Peruvian sign language. The laws had different fortunes: while Law 29524 was regulated the following year with the Supreme Decree 006-2011-MIMDES, the second piece of legislation was only regulated recently, as part of Supreme Decree 006-2017-MIMP.3134995560578000Both laws and their regulations mandate the Ministry of Education to approve complementary provisions on the requirements and profile of interpreter-guides and sign language interpreters.However, the Ministry of Education failed to take immediate action, and so Sense International Peru designed and implemented a training programme for interpreter-guides in 2011. The programme sought to create good practice and tangible evidence that would help the Peruvian authorities to regulate, adopt and scale the service. ?Subsequently, in 2012, coordinated efforts were undertaken between the Directorate of Special Education of the Ministry of Education to prepare the profile and requirements of the interpreter-guide; however, the proposals developed were never approved.In parallel, Sense International Peru worked with CONADIS to create a register of interpreters and interpreter-guides. This was achieved through the approval of the Resolution of the Presidency 020-2017-CONADIS/PRE. This registers interpreters and interpreter-guides accredited by the Ministry of Education.19913602616835Ministry of Education Sectoral Commission members with SIP Director0Ministry of Education Sectoral Commission members with SIP DirectorAt the beginning of 2017, the Ministry of Education had still not approved the complementary provisions for interpreter-guides mandated by law. Sense International Peru once again recalled the Ministry’s legal obligation to approve these requirements and suggested the creation of a working group to develop a proposal. In October 2017, the Direction of Special Education of the Ministry of Education convened the Civil Society Organisations (CSO) to two round table working groups to develop the requirements and profiles of interpreters and interpreter-guides. By the end of December, both groups had developed concrete proposals for approval.1998345217360500However, continuous changes of Ministers of Education and Directors of Special Education have delayed the process. For this reason, in early 2018, Sense International Peru supported the creation of a formal Sectoral Commission, which included all of the Directorates of the Ministry of Education, with the purpose of creating a formative proposal for interpreters and interpreter-guides.On April 2018, the Ministerial Resolution 144-2018-MINEDU was approved, making the Sectoral Commission responsible for formulating a training proposal for interpreters and interpreter-guides. The Commission was given a deadline of 180 days to submit a proposal to the Minister of Education, who must approve it.Such difficult and slow translation of legislative gains and achievements is all too common across countries. It highlights the importance of the strong and continuous mobilisation of persons with deafblindness and their allies in order to successfully develop practice, conduct legal advocacy and engage with authorities. Access to specific support services The survey identified a scarcity of services for persons with deafblindness. It is important to note that, even when a service is said to be available, it does not mean that this service is actually available in all areas of the country and in adequate quantity. Services may be provided in some states and/or provinces but not in others, e.g. in urban rather than rural areas. As expected, support services are far more widely available in high-income countries. However, it is to be noted that interpreter-guides are available in only 58% of high-income countries and 42% provide government-funded interpreter-guide services. The situation is more challenging in low and middle-income countries. Interpreter-guide services are only provided in 10% of countries (N=31; low and upper-middle income countries), with only one country providing government funding. There is, however, higher availability of regular communication and mobility-only services. 0-24%; 25-49%50-74%; 75-100%High-income countries (N=19)Upper-middle income countries (N=13)Lower-middle and low-income countries (N=18)ALL(N=50)Availability of professional interpreter-guides63%15%6%30%Does the government pay for interpreter-guide services?42%8%0%20%Availability of professional mobility support 74%15%22%40%Availability of professional support for accessing information63%31%33%44%An exchange between WFDB members at the 2018 Helen Keller World Conference confirmed the scarcity of interpreter-guide and interpretation services for persons with deafblindness. A lack of awareness and recognition of the specific requirements of persons with deafblindness leads to confusion and an overreliance on specific services for blind and deaf people, which are also limited.“Sign language is not a communication system, it is a language used by persons that are deaf. For many persons with deafblindness it is part of the communication system that includes other elements, different receptions and emission channels (not only visual but also tactile), creating a system that is tailored to the individual.” (participant at 2018 HKWC consultation)Good practice does exist, however. In Spain, for instance, Law 27/2007 recognises the specific communication systems used by persons with deafblindness.In most low and middle-income countries, the few existing services that do exist are concentrated in major cities and there is little to no provision in rural and remote areas. A combined lack of awareness and the relatively small number of persons with deafblindness results in significant underinvestment. “(…) the government does not realise that some deafblind people need interpreters all day. The government only look at the numbers. They discriminate, and they need to look at us like people and understand our full requirements.” (participant at 2018 HKWC consultation)The scarcity of resources can lead to competitive behaviour between groups, with service providers for deaf people occasionally monopolising interpretation services to secure funding. In countries such as Croatia, however, effective collaboration takes place between organisations of deaf and deafblind people. The lack of services severely restricts the social and economic participation of persons with deafblindness, as well as increasing their dependency. “There are few interpreters and the government does not pay for those services. We have to pay or use family and friends as interpreters. Everyone has to find the guide interpreter to get and keep a job but we have to pay for their services and that takes 50% of a person’s salary.”Whilst the situation is better in higher-income countries, major issues still exist. Few countries fully recognise and acknowledge the specific requirements of persons with deafblindness, and therefore there remains a lack of adequate services. Where services do exist, the financial support provided by government is often limited and does not adequately cover the work, family and community participation needs of persons with disabilities. Comments and feedback from WFDB members suggest that the awareness of government decision-makers, proactive DPOs and service providers may be more important than a country’s wealth in terms of the development of appropriate services. Some countries, including Japan, Australia and a number of Scandinavian nations, have been cited as the most developed in terms of service provision. These countries provide trained interpreter services funded by local, regional and central governments, reflecting the required diversity of services (braille, whisper, sign interpretation and haptic signals, amongst others), as well as offering support in the workplace. However, in many high-income countries, the specificities of deafblindness remain unacknowledged, and as a result support services are either non-existent or insufficient. Another issue is unequal access to services within countries that have high level of decentralisation, as well as limited access to services. For example, in some areas of certain countries, where the number of hours of interpretation granted to persons with deafblindness have been cut. Whilst the current situation is unsatisfactory, some progress is being made, and there may be a growing trend towards broader recognition of deafblindness in a number of countries. For example, in situations where national recognition is lacking, some sub-national authorities are taking action. In India, for example, some states have issued certificates specifying deafblindness as a distinct disability, despite the national government categorising the term as a multiple disability. RecommendationsFor countries:In line with CRPD, ensure access to support services that facilitate inclusion and independent living, and enable access to information, communication and mobility. This could be achieved by:Officially recognising the specificity of accessibility and support service requirements for persons with deafblindness.Developing partnerships with DPOs, NGOs and the private sector to ensure the development of support services across sectors.Ensuring adequate and sustainable funding for existing and newly created services.Ensuring access to affordable and high quality assistive devices. Refrain from decreasing the level of support currently provided to persons with deafblindness.Increase international cooperation between countries that have developed adequate support systems and those that are willing to engage.Include accessibility and non-discrimination requirements in all public procurements, including goods and services, as well as in accreditation and licensing for telecommunication services, amongst others. For the UN and development agencies:Support governments to develop support services, including technical and financial assistance, and facilitate international technological exchange. Include accessibility and non-discrimination requirements in public procurement regulations.Making telecommunications accessible: The critical role of public and private sector collaborationAt the 2018 Helen Keller World Conference, Ryan Bondroff, Consumer Relationship Manager for Sprint, presented a range of accessibility services provided in the United States, and outlined the company’s partnership with federal and state governments to provide barrier free telecommunication to persons with deafblindness. Sprint Accessibility offers communication products and services that eliminate communication barriers for customers who are deaf, deafblind, have a hearing or vision loss, and cognitive, speech or mobility disabilities. Those services include the Sprint IP Relay which is fully accessible to persons with deafblindness, supporting them to make and receive relay calls independently via large print or braille formats on mobile devices and computers. Aside from network connectivity, three pre-conditions are required to create an environment that allows the development of such services:Governments need to understand and acknowledge the specific communication requirements of persons with deafblindness to effectively support full access.A relay service provider (RSP) needs to be established.A dialogue and agreement should be put in place between the government, the RSP and telecommunications operators. Sprint wants to help create the right environment and partnerships by facilitating a dialogue between stakeholders to set up a RSP. For instance, Sprint has been contracted to introduce a relay service in New Zealand following the government’s decision to establish a service for the deaf, deafblind and hard of hearing communities.Making telecommunications accessible: The critical role of public and private sector collaborationAt the 2018 Helen Keller World Conference, Ryan Bondroff, Consumer Relationship Manager for Sprint, presented a range of accessibility services provided in the United States, and outlined the company’s partnership with federal and state governments to provide barrier free telecommunication to persons with deafblindness. Sprint Accessibility offers communication products and services that eliminate communication barriers for customers who are deaf, deafblind, have a hearing or vision loss, and cognitive, speech or mobility disabilities. Those services include the Sprint IP Relay which is fully accessible to persons with deafblindness, supporting them to make and receive relay calls independently via large print or braille formats on mobile devices and computers. Aside from network connectivity, three pre-conditions are required to create an environment that allows the development of such services:Governments need to understand and acknowledge the specific communication requirements of persons with deafblindness to effectively support full access.A relay service provider (RSP) needs to be established.A dialogue and agreement should be put in place between the government, the RSP and telecommunications operators. Sprint wants to help create the right environment and partnerships by facilitating a dialogue between stakeholders to set up a RSP. For instance, Sprint has been contracted to introduce a relay service in New Zealand following the government’s decision to establish a service for the deaf, deafblind and hard of hearing communities.Persons with deafblindness and inequalityThe data collection undertaken for this report combines a review of academic literature and two surveys undertaken amongst members and partners of WFDB and Sense International, as well as case studies. Additionally, a quantitative analysis of census and other large survey data was undertaken, representing the largest and most internationally representative analysis of the situation of deafblindness conducted to date.The majority of the available literature came from the United States and European countries, and almost no studies were identified from low and middle-income nations. As such, a specific focus has been placed on quantitative data analysis and fact-finding from the global South.At the 2018 Helen Keller World Conference, the findings from this research were presented to WFDB members. Women and men with deafblindness enriched this information with their personal experiences and elaborated on the recommendations.Methodology Review of the literaturePubMed, Google Scholar, Web of Science and Education Resources Information Centre (ERIC) were searched between August and November 2017. Search terms included ‘deafblindness’, ‘dual sensory impairment’ and combinations of ‘deaf’ and ‘blind’, ‘visual impairment’ and ‘hearing impairment’. References made to relevant articles were also checked to obtain additional sources. Studies were included in the review if they were written in English or French, focused on measurements of deafblindness (definitions, estimates of prevalence and causes), or the impact of deafblindness. There were no restrictions by study location or setting. Country data analysesFigure 1. Countries included in the data analysisFigure 1. Countries included in the data analysisNationally representative population-based surveys from 22 countries were used to measure the prevalence of deafblindness (see Figure 1). Eleven of these countries were selected for further detailed analysis based on their relevance, particularly in relation to how they measured deafblindness and whether they provided a large enough sample size to complete an analysis. Consideration was given to ensuring representation by region and country income group. In total, over 97.6 million people were included across the 22 datasets. This is the largest population-based analysis on deafblindness conducted to date and includes evidence from a variety of regions and country income groups.Statistical Appendix 1 provides an in-depth look at the data analysis methods employed, including an explanation of key statistical terms, such as ‘95% confidence’ and ‘odds ratios’.WFDB and Sense International member and partner surveysTo fully identify the issues and remove the barriers experienced by persons with deafblindness, it is essential to harness the perspectives of support organisations. A survey was conducted amongst all member organisations of the WFDB. The WFDB survey was distributed to 76 associations of persons with deafblindness with a response rate of 56% (43 answers). The same approach was used to undertake a survey amongst professionals working with or for persons with deafblindness on a global scale. Sense International and WFDB disseminated the questionnaire to Sense International country programmes, International Disability and Development Consortium (IDDC) members and DbI (Deafblind International) members. A total of 20 questionnaires were returned. In combination, the two surveys allowed the collection and collation of information from organisations of persons with deafblindness and their allies from 50 countries, as follows:High-income countries: Australia, Chile, Canada, Sweden, Spain, Switzerland, Japan, Macau (China), Austria, Belgium, USA, Uruguay, Hungary, Italy, Czech Republic, Norway, Denmark, and Germany.Upper middle-income countries: South Africa, Malaysia, Dominican Republic, Romania, Croatia, Russia, Peru, Brazil, Colombia, Ecuador, Mexico, Venezuela, and Thailand.Lower middle-income and low-income countries: India, Ghana, Bangladesh, Guatemala, Salvador, Kenya, Uganda, Tanzania,?Ethiopia, Malawi, Nepal, Philippines, Bolivia, Honduras, Nicaragua, Ivory Coast, Nigeria, and Zambia.The challenges of ‘counting’ persons with deafblindness The literature reviewed provided contrasting definitions and measurements of deafblindness, with no agreement on ‘best practice’ PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYW1tZXllcjwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

PFJlY051bT4xPC9SZWNOdW0+PERpc3BsYXlUZXh0Pls3LCAxMCwgMTFdPC9EaXNwbGF5VGV4dD48

cmVjb3JkPjxyZWMtbnVtYmVyPjE8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0i

RU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFt

cD0iMTUyNzg0MTk1NyI+MTwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3Vy

bmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+

RGFtbWV5ZXIsIEplc3BlcjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVz

Pjx0aXRsZT5EZWFmYmxpbmRuZXNzOiBhIHJldmlldyBvZiB0aGUgbGl0ZXJhdHVyZTwvdGl0bGU+

PHNlY29uZGFyeS10aXRsZT5TY2FuZGluYXZpYW4gam91cm5hbCBvZiBwdWJsaWMgaGVhbHRoPC9z

ZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+U2NhbmRpbmF2

aWFuIGpvdXJuYWwgb2YgcHVibGljIGhlYWx0aDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBh

Z2VzPjU1NC01NjI8L3BhZ2VzPjx2b2x1bWU+NDI8L3ZvbHVtZT48bnVtYmVyPjc8L251bWJlcj48

ZGF0ZXM+PHllYXI+MjAxNDwveWVhcj48L2RhdGVzPjxpc2JuPjE0MDMtNDk0ODwvaXNibj48dXJs

cz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+U2NobmVpZGVyPC9BdXRob3I+

PFllYXI+MjAxMTwvWWVhcj48UmVjTnVtPjI8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjI8

L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0

ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+Mjwva2V5

PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYt

dHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+U2NobmVpZGVyLCBKdWxpZSBNPC9h

dXRob3I+PGF1dGhvcj5Hb3BpbmF0aCwgQmFtaW5pPC9hdXRob3I+PGF1dGhvcj5NY01haG9uLCBD

YXRoZXJpbmUgTTwvYXV0aG9yPjxhdXRob3I+TGVlZGVyLCBTdGVwaGVuIFI8L2F1dGhvcj48YXV0

aG9yPk1pdGNoZWxsLCBQYXVsPC9hdXRob3I+PGF1dGhvcj5XYW5nLCBKaWUgSmluPC9hdXRob3I+

PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkR1YWwgc2Vuc29yeSBpbXBh

aXJtZW50IGluIG9sZGVyIGFnZTwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5Kb3VybmFsIG9mIEFn

aW5nIGFuZCBIZWFsdGg8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVs

bC10aXRsZT5Kb3VybmFsIG9mIEFnaW5nIGFuZCBIZWFsdGg8L2Z1bGwtdGl0bGU+PC9wZXJpb2Rp

Y2FsPjxwYWdlcz4xMzA5LTEzMjQ8L3BhZ2VzPjx2b2x1bWU+MjM8L3ZvbHVtZT48bnVtYmVyPjg8

L251bWJlcj48ZGF0ZXM+PHllYXI+MjAxMTwveWVhcj48L2RhdGVzPjxpc2JuPjA4OTgtMjY0Mzwv

aXNibj48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+U2ltY29jazwv

QXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJlY051bT4zPC9SZWNOdW0+PHJlY29yZD48cmVjLW51

bWJlcj4zPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRk

dnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTci

PjM8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4x

NzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPlNpbWNvY2ssIFBldGVy

PC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPk9uZSBvZiBz

b2NpZXR5JmFwb3M7cyBtb3N0IHZ1bG5lcmFibGUgZ3JvdXBzPyBBIHN5c3RlbWF0aWNhbGx5IGNv

bmR1Y3RlZCBsaXRlcmF0dXJlIHJldmlldyBleHBsb3JpbmcgdGhlIHZ1bG5lcmFiaWxpdHkgb2Yg

ZGVhZmJsaW5kIHBlb3BsZTwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5IZWFsdGggJmFtcDsgc29j

aWFsIGNhcmUgaW4gdGhlIGNvbW11bml0eTwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJp

b2RpY2FsPjxmdWxsLXRpdGxlPkhlYWx0aCAmYW1wOyBzb2NpYWwgY2FyZSBpbiB0aGUgY29tbXVu

aXR5PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+ODEzLTgzOTwvcGFnZXM+PHZvbHVt

ZT4yNTwvdm9sdW1lPjxudW1iZXI+MzwvbnVtYmVyPjxkYXRlcz48eWVhcj4yMDE3PC95ZWFyPjwv

ZGF0ZXM+PGlzYm4+MTM2NS0yNTI0PC9pc2JuPjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+

PC9FbmROb3RlPgB=

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYW1tZXllcjwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

PFJlY051bT4xPC9SZWNOdW0+PERpc3BsYXlUZXh0Pls3LCAxMCwgMTFdPC9EaXNwbGF5VGV4dD48

cmVjb3JkPjxyZWMtbnVtYmVyPjE8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0i

RU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFt

cD0iMTUyNzg0MTk1NyI+MTwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3Vy

bmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+

RGFtbWV5ZXIsIEplc3BlcjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVz

Pjx0aXRsZT5EZWFmYmxpbmRuZXNzOiBhIHJldmlldyBvZiB0aGUgbGl0ZXJhdHVyZTwvdGl0bGU+

PHNlY29uZGFyeS10aXRsZT5TY2FuZGluYXZpYW4gam91cm5hbCBvZiBwdWJsaWMgaGVhbHRoPC9z

ZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+U2NhbmRpbmF2

aWFuIGpvdXJuYWwgb2YgcHVibGljIGhlYWx0aDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBh

Z2VzPjU1NC01NjI8L3BhZ2VzPjx2b2x1bWU+NDI8L3ZvbHVtZT48bnVtYmVyPjc8L251bWJlcj48

ZGF0ZXM+PHllYXI+MjAxNDwveWVhcj48L2RhdGVzPjxpc2JuPjE0MDMtNDk0ODwvaXNibj48dXJs

cz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+U2NobmVpZGVyPC9BdXRob3I+

PFllYXI+MjAxMTwvWWVhcj48UmVjTnVtPjI8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjI8

L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0

ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+Mjwva2V5

PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYt

dHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+U2NobmVpZGVyLCBKdWxpZSBNPC9h

dXRob3I+PGF1dGhvcj5Hb3BpbmF0aCwgQmFtaW5pPC9hdXRob3I+PGF1dGhvcj5NY01haG9uLCBD

YXRoZXJpbmUgTTwvYXV0aG9yPjxhdXRob3I+TGVlZGVyLCBTdGVwaGVuIFI8L2F1dGhvcj48YXV0

aG9yPk1pdGNoZWxsLCBQYXVsPC9hdXRob3I+PGF1dGhvcj5XYW5nLCBKaWUgSmluPC9hdXRob3I+

PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkR1YWwgc2Vuc29yeSBpbXBh

aXJtZW50IGluIG9sZGVyIGFnZTwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5Kb3VybmFsIG9mIEFn

aW5nIGFuZCBIZWFsdGg8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVs

bC10aXRsZT5Kb3VybmFsIG9mIEFnaW5nIGFuZCBIZWFsdGg8L2Z1bGwtdGl0bGU+PC9wZXJpb2Rp

Y2FsPjxwYWdlcz4xMzA5LTEzMjQ8L3BhZ2VzPjx2b2x1bWU+MjM8L3ZvbHVtZT48bnVtYmVyPjg8

L251bWJlcj48ZGF0ZXM+PHllYXI+MjAxMTwveWVhcj48L2RhdGVzPjxpc2JuPjA4OTgtMjY0Mzwv

aXNibj48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+U2ltY29jazwv

QXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJlY051bT4zPC9SZWNOdW0+PHJlY29yZD48cmVjLW51

bWJlcj4zPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRk

dnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTci

PjM8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4x

NzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPlNpbWNvY2ssIFBldGVy

PC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPk9uZSBvZiBz

b2NpZXR5JmFwb3M7cyBtb3N0IHZ1bG5lcmFibGUgZ3JvdXBzPyBBIHN5c3RlbWF0aWNhbGx5IGNv

bmR1Y3RlZCBsaXRlcmF0dXJlIHJldmlldyBleHBsb3JpbmcgdGhlIHZ1bG5lcmFiaWxpdHkgb2Yg

ZGVhZmJsaW5kIHBlb3BsZTwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5IZWFsdGggJmFtcDsgc29j

aWFsIGNhcmUgaW4gdGhlIGNvbW11bml0eTwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJp

b2RpY2FsPjxmdWxsLXRpdGxlPkhlYWx0aCAmYW1wOyBzb2NpYWwgY2FyZSBpbiB0aGUgY29tbXVu

aXR5PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+ODEzLTgzOTwvcGFnZXM+PHZvbHVt

ZT4yNTwvdm9sdW1lPjxudW1iZXI+MzwvbnVtYmVyPjxkYXRlcz48eWVhcj4yMDE3PC95ZWFyPjwv

ZGF0ZXM+PGlzYm4+MTM2NS0yNTI0PC9pc2JuPjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+

PC9FbmROb3RlPgB=

ADDIN EN.CITE.DATA [7, 10, 11]. In broad terms, definitions of deafblindness fell into two major categories ADDIN EN.CITE <EndNote><Cite><Author>Dammeyer</Author><Year>2014</Year><RecNum>1</RecNum><DisplayText>[10]</DisplayText><record><rec-number>1</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">1</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dammeyer, Jesper</author></authors></contributors><titles><title>Deafblindness: a review of the literature</title><secondary-title>Scandinavian journal of public health</secondary-title></titles><periodical><full-title>Scandinavian journal of public health</full-title></periodical><pages>554-562</pages><volume>42</volume><number>7</number><dates><year>2014</year></dates><isbn>1403-4948</isbn><urls></urls></record></Cite></EndNote>[10]: definitions (clinical assessments of the level of hearing and visual impairment); or functioning-based definitions (self-reported or observations of a person’s ability to hear and see, and its impact on the individual’s participation in everyday activities). Even within these categories, significant variations in criteria were used to determine deafblindness. For example, different thresholds of hearing and visual loss in clinical assessments were identified across the studies. The lack of a clear, consistently used definition of deafblindness makes it difficult to gather data that is comparable between studies, settings and over time PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYW1tZXllcjwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

PFJlY051bT4xPC9SZWNOdW0+PERpc3BsYXlUZXh0Pls3LCA5LTExXTwvRGlzcGxheVRleHQ+PHJl

Y29yZD48cmVjLW51bWJlcj4xPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVO

IiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9

IjE1Mjc4NDE5NTciPjE8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5h

bCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkRh

bW1leWVyLCBKZXNwZXI8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PHRpdGxlcz48

dGl0bGU+RGVhZmJsaW5kbmVzczogYSByZXZpZXcgb2YgdGhlIGxpdGVyYXR1cmU8L3RpdGxlPjxz

ZWNvbmRhcnktdGl0bGU+U2NhbmRpbmF2aWFuIGpvdXJuYWwgb2YgcHVibGljIGhlYWx0aDwvc2Vj

b25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPlNjYW5kaW5hdmlh

biBqb3VybmFsIG9mIHB1YmxpYyBoZWFsdGg8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdl

cz41NTQtNTYyPC9wYWdlcz48dm9sdW1lPjQyPC92b2x1bWU+PG51bWJlcj43PC9udW1iZXI+PGRh

dGVzPjx5ZWFyPjIwMTQ8L3llYXI+PC9kYXRlcz48aXNibj4xNDAzLTQ5NDg8L2lzYm4+PHVybHM+

PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPlNjaG5laWRlcjwvQXV0aG9yPjxZ

ZWFyPjIwMTE8L1llYXI+PFJlY051bT4yPC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4yPC9y

ZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZk

MjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTciPjI8L2tleT48

L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5

cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPlNjaG5laWRlciwgSnVsaWUgTTwvYXV0

aG9yPjxhdXRob3I+R29waW5hdGgsIEJhbWluaTwvYXV0aG9yPjxhdXRob3I+TWNNYWhvbiwgQ2F0

aGVyaW5lIE08L2F1dGhvcj48YXV0aG9yPkxlZWRlciwgU3RlcGhlbiBSPC9hdXRob3I+PGF1dGhv

cj5NaXRjaGVsbCwgUGF1bDwvYXV0aG9yPjxhdXRob3I+V2FuZywgSmllIEppbjwvYXV0aG9yPjwv

YXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5EdWFsIHNlbnNvcnkgaW1wYWly

bWVudCBpbiBvbGRlciBhZ2U8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+Sm91cm5hbCBvZiBBZ2lu

ZyBhbmQgSGVhbHRoPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwt

dGl0bGU+Sm91cm5hbCBvZiBBZ2luZyBhbmQgSGVhbHRoPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNh

bD48cGFnZXM+MTMwOS0xMzI0PC9wYWdlcz48dm9sdW1lPjIzPC92b2x1bWU+PG51bWJlcj44PC9u

dW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTE8L3llYXI+PC9kYXRlcz48aXNibj4wODk4LTI2NDM8L2lz

Ym4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPlNjaG5laWRlcjwv

QXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PFJlY051bT4yPC9SZWNOdW0+PHJlY29yZD48cmVjLW51

bWJlcj4yPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRk

dnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTci

PjI8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4x

NzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPlNjaG5laWRlciwgSnVs

aWUgTTwvYXV0aG9yPjxhdXRob3I+R29waW5hdGgsIEJhbWluaTwvYXV0aG9yPjxhdXRob3I+TWNN

YWhvbiwgQ2F0aGVyaW5lIE08L2F1dGhvcj48YXV0aG9yPkxlZWRlciwgU3RlcGhlbiBSPC9hdXRo

b3I+PGF1dGhvcj5NaXRjaGVsbCwgUGF1bDwvYXV0aG9yPjxhdXRob3I+V2FuZywgSmllIEppbjwv

YXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5EdWFsIHNlbnNv

cnkgaW1wYWlybWVudCBpbiBvbGRlciBhZ2U8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+Sm91cm5h

bCBvZiBBZ2luZyBhbmQgSGVhbHRoPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGlj

YWw+PGZ1bGwtdGl0bGU+Sm91cm5hbCBvZiBBZ2luZyBhbmQgSGVhbHRoPC9mdWxsLXRpdGxlPjwv

cGVyaW9kaWNhbD48cGFnZXM+MTMwOS0xMzI0PC9wYWdlcz48dm9sdW1lPjIzPC92b2x1bWU+PG51

bWJlcj44PC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTE8L3llYXI+PC9kYXRlcz48aXNibj4wODk4

LTI2NDM8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPlNp

bWNvY2s8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxSZWNOdW0+NTY8L1JlY051bT48cmVjb3Jk

PjxyZWMtbnVtYmVyPjU2PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBk

Yi1pZD0iNTJ3dnByNTlocHd6d2Zlc3R3cjVld3R2cGF3ejBwc3NyNXQ5IiB0aW1lc3RhbXA9IjE1

MTIzOTg0MDAiPjU2PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwg

QXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5TaW1j

b2NrLCBQZXRlcjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRs

ZT5BZ2Vpbmcgd2l0aCBhIHVuaXF1ZSBpbXBhaXJtZW50OiBhIHN5c3RlbWF0aWNhbGx5IGNvbmR1

Y3RlZCByZXZpZXcgb2Ygb2xkZXIgZGVhZmJsaW5kIHBlb3BsZSZhcG9zO3MgZXhwZXJpZW5jZXM8

L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+QWdlaW5nICZhbXA7IFNvY2lldHk8L3NlY29uZGFyeS10

aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5BZ2VpbmcgJmFtcDsgU29jaWV0

eTwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjE3MDMtMTc0MjwvcGFnZXM+PHZvbHVt

ZT4zNzwvdm9sdW1lPjxudW1iZXI+ODwvbnVtYmVyPjxkYXRlcz48eWVhcj4yMDE3PC95ZWFyPjwv

ZGF0ZXM+PGlzYm4+MDE0NC02ODZYPC9pc2JuPjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+

PENpdGU+PEF1dGhvcj5TaW1jb2NrPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48UmVjTnVtPjM8

L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjM8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48

a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3gi

IHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+Mzwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBu

YW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3Jz

PjxhdXRob3I+U2ltY29jaywgUGV0ZXI8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+

PHRpdGxlcz48dGl0bGU+T25lIG9mIHNvY2lldHkmYXBvcztzIG1vc3QgdnVsbmVyYWJsZSBncm91

cHM/IEEgc3lzdGVtYXRpY2FsbHkgY29uZHVjdGVkIGxpdGVyYXR1cmUgcmV2aWV3IGV4cGxvcmlu

ZyB0aGUgdnVsbmVyYWJpbGl0eSBvZiBkZWFmYmxpbmQgcGVvcGxlPC90aXRsZT48c2Vjb25kYXJ5

LXRpdGxlPkhlYWx0aCAmYW1wOyBzb2NpYWwgY2FyZSBpbiB0aGUgY29tbXVuaXR5PC9zZWNvbmRh

cnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+SGVhbHRoICZhbXA7IHNv

Y2lhbCBjYXJlIGluIHRoZSBjb21tdW5pdHk8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdl

cz44MTMtODM5PC9wYWdlcz48dm9sdW1lPjI1PC92b2x1bWU+PG51bWJlcj4zPC9udW1iZXI+PGRh

dGVzPjx5ZWFyPjIwMTc8L3llYXI+PC9kYXRlcz48aXNibj4xMzY1LTI1MjQ8L2lzYm4+PHVybHM+

PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48L0VuZE5vdGU+

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYW1tZXllcjwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+

PFJlY051bT4xPC9SZWNOdW0+PERpc3BsYXlUZXh0Pls3LCA5LTExXTwvRGlzcGxheVRleHQ+PHJl

Y29yZD48cmVjLW51bWJlcj4xPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVO

IiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9

IjE1Mjc4NDE5NTciPjE8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5h

bCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkRh

bW1leWVyLCBKZXNwZXI8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PHRpdGxlcz48

dGl0bGU+RGVhZmJsaW5kbmVzczogYSByZXZpZXcgb2YgdGhlIGxpdGVyYXR1cmU8L3RpdGxlPjxz

ZWNvbmRhcnktdGl0bGU+U2NhbmRpbmF2aWFuIGpvdXJuYWwgb2YgcHVibGljIGhlYWx0aDwvc2Vj

b25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPlNjYW5kaW5hdmlh

biBqb3VybmFsIG9mIHB1YmxpYyBoZWFsdGg8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdl

cz41NTQtNTYyPC9wYWdlcz48dm9sdW1lPjQyPC92b2x1bWU+PG51bWJlcj43PC9udW1iZXI+PGRh

dGVzPjx5ZWFyPjIwMTQ8L3llYXI+PC9kYXRlcz48aXNibj4xNDAzLTQ5NDg8L2lzYm4+PHVybHM+

PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPlNjaG5laWRlcjwvQXV0aG9yPjxZ

ZWFyPjIwMTE8L1llYXI+PFJlY051bT4yPC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4yPC9y

ZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZk

MjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTciPjI8L2tleT48

L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5

cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPlNjaG5laWRlciwgSnVsaWUgTTwvYXV0

aG9yPjxhdXRob3I+R29waW5hdGgsIEJhbWluaTwvYXV0aG9yPjxhdXRob3I+TWNNYWhvbiwgQ2F0

aGVyaW5lIE08L2F1dGhvcj48YXV0aG9yPkxlZWRlciwgU3RlcGhlbiBSPC9hdXRob3I+PGF1dGhv

cj5NaXRjaGVsbCwgUGF1bDwvYXV0aG9yPjxhdXRob3I+V2FuZywgSmllIEppbjwvYXV0aG9yPjwv

YXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5EdWFsIHNlbnNvcnkgaW1wYWly

bWVudCBpbiBvbGRlciBhZ2U8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+Sm91cm5hbCBvZiBBZ2lu

ZyBhbmQgSGVhbHRoPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwt

dGl0bGU+Sm91cm5hbCBvZiBBZ2luZyBhbmQgSGVhbHRoPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNh

bD48cGFnZXM+MTMwOS0xMzI0PC9wYWdlcz48dm9sdW1lPjIzPC92b2x1bWU+PG51bWJlcj44PC9u

dW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTE8L3llYXI+PC9kYXRlcz48aXNibj4wODk4LTI2NDM8L2lz

Ym4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPlNjaG5laWRlcjwv

QXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PFJlY051bT4yPC9SZWNOdW0+PHJlY29yZD48cmVjLW51

bWJlcj4yPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRk

dnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTci

PjI8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4x

NzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPlNjaG5laWRlciwgSnVs

aWUgTTwvYXV0aG9yPjxhdXRob3I+R29waW5hdGgsIEJhbWluaTwvYXV0aG9yPjxhdXRob3I+TWNN

YWhvbiwgQ2F0aGVyaW5lIE08L2F1dGhvcj48YXV0aG9yPkxlZWRlciwgU3RlcGhlbiBSPC9hdXRo

b3I+PGF1dGhvcj5NaXRjaGVsbCwgUGF1bDwvYXV0aG9yPjxhdXRob3I+V2FuZywgSmllIEppbjwv

YXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5EdWFsIHNlbnNv

cnkgaW1wYWlybWVudCBpbiBvbGRlciBhZ2U8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+Sm91cm5h

bCBvZiBBZ2luZyBhbmQgSGVhbHRoPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGlj

YWw+PGZ1bGwtdGl0bGU+Sm91cm5hbCBvZiBBZ2luZyBhbmQgSGVhbHRoPC9mdWxsLXRpdGxlPjwv

cGVyaW9kaWNhbD48cGFnZXM+MTMwOS0xMzI0PC9wYWdlcz48dm9sdW1lPjIzPC92b2x1bWU+PG51

bWJlcj44PC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTE8L3llYXI+PC9kYXRlcz48aXNibj4wODk4

LTI2NDM8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPlNp

bWNvY2s8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxSZWNOdW0+NTY8L1JlY051bT48cmVjb3Jk

PjxyZWMtbnVtYmVyPjU2PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBk

Yi1pZD0iNTJ3dnByNTlocHd6d2Zlc3R3cjVld3R2cGF3ejBwc3NyNXQ5IiB0aW1lc3RhbXA9IjE1

MTIzOTg0MDAiPjU2PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwg

QXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5TaW1j

b2NrLCBQZXRlcjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRs

ZT5BZ2Vpbmcgd2l0aCBhIHVuaXF1ZSBpbXBhaXJtZW50OiBhIHN5c3RlbWF0aWNhbGx5IGNvbmR1

Y3RlZCByZXZpZXcgb2Ygb2xkZXIgZGVhZmJsaW5kIHBlb3BsZSZhcG9zO3MgZXhwZXJpZW5jZXM8

L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+QWdlaW5nICZhbXA7IFNvY2lldHk8L3NlY29uZGFyeS10

aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5BZ2VpbmcgJmFtcDsgU29jaWV0

eTwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjE3MDMtMTc0MjwvcGFnZXM+PHZvbHVt

ZT4zNzwvdm9sdW1lPjxudW1iZXI+ODwvbnVtYmVyPjxkYXRlcz48eWVhcj4yMDE3PC95ZWFyPjwv

ZGF0ZXM+PGlzYm4+MDE0NC02ODZYPC9pc2JuPjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+

PENpdGU+PEF1dGhvcj5TaW1jb2NrPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48UmVjTnVtPjM8

L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjM8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48

a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3gi

IHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+Mzwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBu

YW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3Jz

PjxhdXRob3I+U2ltY29jaywgUGV0ZXI8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+

PHRpdGxlcz48dGl0bGU+T25lIG9mIHNvY2lldHkmYXBvcztzIG1vc3QgdnVsbmVyYWJsZSBncm91

cHM/IEEgc3lzdGVtYXRpY2FsbHkgY29uZHVjdGVkIGxpdGVyYXR1cmUgcmV2aWV3IGV4cGxvcmlu

ZyB0aGUgdnVsbmVyYWJpbGl0eSBvZiBkZWFmYmxpbmQgcGVvcGxlPC90aXRsZT48c2Vjb25kYXJ5

LXRpdGxlPkhlYWx0aCAmYW1wOyBzb2NpYWwgY2FyZSBpbiB0aGUgY29tbXVuaXR5PC9zZWNvbmRh

cnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+SGVhbHRoICZhbXA7IHNv

Y2lhbCBjYXJlIGluIHRoZSBjb21tdW5pdHk8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdl

cz44MTMtODM5PC9wYWdlcz48dm9sdW1lPjI1PC92b2x1bWU+PG51bWJlcj4zPC9udW1iZXI+PGRh

dGVzPjx5ZWFyPjIwMTc8L3llYXI+PC9kYXRlcz48aXNibj4xMzY1LTI1MjQ8L2lzYm4+PHVybHM+

PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48L0VuZE5vdGU+

ADDIN EN.CITE.DATA [7, 9-11]. However, across the range of definitions, some commonalities were identified. For example, almost all definitions acknowledged that deafblindness does not only refer to people who are both deaf and blind, but include people with some vision and/or hearing ADDIN EN.CITE <EndNote><Cite><Author>Saunders</Author><Year>2007</Year><RecNum>32</RecNum><DisplayText>[12]</DisplayText><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">32</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Saunders, Gabrielle H</author><author>Echt, Katharina V</author></authors></contributors><titles><title>An overview of dual sensory impairment in older adults: perspectives for rehabilitation</title><secondary-title>Trends in amplification</secondary-title></titles><periodical><full-title>Trends in amplification</full-title></periodical><pages>243-258</pages><volume>11</volume><number>4</number><dates><year>2007</year></dates><isbn>1084-7138</isbn><urls></urls></record></Cite></EndNote>[12]. A key characteristic of deafblindness is the combined effect of hearing and vision loss on a person’s ability to communicate, so that the severity of each impairment is such that one sense cannot compensate for the other ADDIN EN.CITE <EndNote><Cite><Author>Dammeyer</Author><Year>2014</Year><RecNum>1</RecNum><DisplayText>[10, 12]</DisplayText><record><rec-number>1</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">1</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dammeyer, Jesper</author></authors></contributors><titles><title>Deafblindness: a review of the literature</title><secondary-title>Scandinavian journal of public health</secondary-title></titles><periodical><full-title>Scandinavian journal of public health</full-title></periodical><pages>554-562</pages><volume>42</volume><number>7</number><dates><year>2014</year></dates><isbn>1403-4948</isbn><urls></urls></record></Cite><Cite><Author>Saunders</Author><Year>2007</Year><RecNum>32</RecNum><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">32</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Saunders, Gabrielle H</author><author>Echt, Katharina V</author></authors></contributors><titles><title>An overview of dual sensory impairment in older adults: perspectives for rehabilitation</title><secondary-title>Trends in amplification</secondary-title></titles><periodical><full-title>Trends in amplification</full-title></periodical><pages>243-258</pages><volume>11</volume><number>4</number><dates><year>2007</year></dates><isbn>1084-7138</isbn><urls></urls></record></Cite></EndNote>[10, 12].No large, population-based studies were identified that measured the all-age prevalence of deafblindness. The analysis of country-level census data, therefore, provides a unique opportunity to estimate the prevalence of deafblindness across a range of contexts. Figure 2 shows the prevalence of deafblindness in each of the 22 country datasets initially explored. The measurement of deafblindness varied across the datasets. For example, in Iran, Indonesia, Ecuador, Venezuela and Haiti, definitions included people who are completely deaf and blind, while the remaining countries also included people with some residual vision and hearing. A sub-set of censuses used the Washington Group Questions, which is an internationally comparable module on reported difficulties with six functional domains, including vision and hearing. Extended analyses are focused on the sub-set of censuses.The prevalence of severe deafblindness (in individuals aged five years and older) across the 22 surveys ranged between 0.01% in Cambodia, Haiti, Iran and Venezuela, to 0.85% in the United States. The weighted prevalence across all datasets was 0.21%. -1809751905000 Figure 2. Prevalence of deafblindness among people aged 5 years and over across 22 countriesIn datasets that used the Washington Group Questions, it was possible to explore the prevalence and different levels of deafblindness. Figure 3 illustrates the prevalence of deafblindness using a lower threshold, whereby ‘some’ or a ‘greater difficulty’ in seeing and hearing was reported. The prevalence of this ‘less severe’ level of deafblindness is much higher than severe deafblindness, and ranges from between 0.4% in Tanzania to 3.1% in Brazil.Figure 3. All-age prevalence of moderate deafblindness using the Washington Group QuestionsFigure 4 details the prevalence of deafblindness in the 11 countries chosen for subsequent analyses throughout the report, stratified by age group. The graph illustrates a strong association between the prevalence of deafblindness and age. In almost all study countries, less than 0.1% of the population aged 40 years and under has deafblindness, and this rises to 6% of the population aged 75 and over. An increased prevalence of deafblindness linked to age is also reflected in the literature review PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2huZWlkZXI8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy

PjxSZWNOdW0+MjwvUmVjTnVtPjxEaXNwbGF5VGV4dD5bMTEsIDEzLTE4XTwvRGlzcGxheVRleHQ+

PHJlY29yZD48cmVjLW51bWJlcj4yPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9

IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3Rh

bXA9IjE1Mjc4NDE5NTciPjI8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91

cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9y

PlNjaG5laWRlciwgSnVsaWUgTTwvYXV0aG9yPjxhdXRob3I+R29waW5hdGgsIEJhbWluaTwvYXV0

aG9yPjxhdXRob3I+TWNNYWhvbiwgQ2F0aGVyaW5lIE08L2F1dGhvcj48YXV0aG9yPkxlZWRlciwg

U3RlcGhlbiBSPC9hdXRob3I+PGF1dGhvcj5NaXRjaGVsbCwgUGF1bDwvYXV0aG9yPjxhdXRob3I+

V2FuZywgSmllIEppbjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0

aXRsZT5EdWFsIHNlbnNvcnkgaW1wYWlybWVudCBpbiBvbGRlciBhZ2U8L3RpdGxlPjxzZWNvbmRh

cnktdGl0bGU+Sm91cm5hbCBvZiBBZ2luZyBhbmQgSGVhbHRoPC9zZWNvbmRhcnktdGl0bGU+PC90

aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+Sm91cm5hbCBvZiBBZ2luZyBhbmQgSGVhbHRo

PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+MTMwOS0xMzI0PC9wYWdlcz48dm9sdW1l

PjIzPC92b2x1bWU+PG51bWJlcj44PC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTE8L3llYXI+PC9k

YXRlcz48aXNibj4wODk4LTI2NDM8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48

Q2l0ZT48QXV0aG9yPkNoaWE8L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFyPjxSZWNOdW0+NDwvUmVj

TnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+NDwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkg

YXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGlt

ZXN0YW1wPSIxNTI3ODQxOTU3Ij40PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9

IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1

dGhvcj5DaGlhLCBFZS1NdW5uPC9hdXRob3I+PGF1dGhvcj5NaXRjaGVsbCwgUGF1bDwvYXV0aG9y

PjxhdXRob3I+Um9jaHRjaGluYSwgRWxlbmE8L2F1dGhvcj48YXV0aG9yPkZvcmFuLCBTdXJpeWE8

L2F1dGhvcj48YXV0aG9yPkdvbGRpbmcsIE1hcnlhbm5lPC9hdXRob3I+PGF1dGhvcj5XYW5nLCBK

aWUgSmluPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkFz

c29jaWF0aW9uIGJldHdlZW4gdmlzaW9uIGFuZCBoZWFyaW5nIGltcGFpcm1lbnRzIGFuZCB0aGVp

ciBjb21iaW5lZCBlZmZlY3RzIG9uIHF1YWxpdHkgb2YgbGlmZTwvdGl0bGU+PHNlY29uZGFyeS10

aXRsZT5BcmNoaXZlcyBvZiBPcGh0aGFsbW9sb2d5PC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+

PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+QXJjaGl2ZXMgb2YgT3BodGhhbG1vbG9neTwvZnVsbC10

aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjE0NjUtMTQ3MDwvcGFnZXM+PHZvbHVtZT4xMjQ8L3Zv

bHVtZT48bnVtYmVyPjEwPC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMDY8L3llYXI+PC9kYXRlcz48

aXNibj4wMDAzLTk5NTA8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48

QXV0aG9yPkhhcmFkYTwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+PFJlY051bT41PC9SZWNOdW0+

PHJlY29yZD48cmVjLW51bWJlcj41PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9

IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3Rh

bXA9IjE1Mjc4NDE5NTciPjU8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91

cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9y

PkhhcmFkYSwgU2VpPC9hdXRob3I+PGF1dGhvcj5OaXNoaXdha2ksIFl1amk8L2F1dGhvcj48YXV0

aG9yPk1pY2hpa2F3YSwgVGFrZWhpcm88L2F1dGhvcj48YXV0aG9yPktpa3VjaGksIFl1cmlrbzwv

YXV0aG9yPjxhdXRob3I+SXdhc2F3YSwgU2F0b2tvPC9hdXRob3I+PGF1dGhvcj5OYWthbm8sIE1h

a2lrbzwvYXV0aG9yPjxhdXRob3I+SXNoaWdhbWksIEFpPC9hdXRob3I+PGF1dGhvcj5TYWl0bywg

SGlkZXl1a2k8L2F1dGhvcj48YXV0aG9yPlRha2ViYXlhc2hpLCBUb3J1PC9hdXRob3I+PC9hdXRo

b3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkdlbmRlciBkaWZmZXJlbmNlIGluIHRo

ZSByZWxhdGlvbnNoaXBzIGJldHdlZW4gdmlzaW9uIGFuZCBoZWFyaW5nIGltcGFpcm1lbnRzIGFu

ZCBuZWdhdGl2ZSB3ZWxsLWJlaW5nPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPlByZXZlbnRpdmUg

bWVkaWNpbmU8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRs

ZT5QcmV2ZW50aXZlIG1lZGljaW5lPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+NDMz

LTQzNzwvcGFnZXM+PHZvbHVtZT40Nzwvdm9sdW1lPjxudW1iZXI+NDwvbnVtYmVyPjxkYXRlcz48

eWVhcj4yMDA4PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDA5MS03NDM1PC9pc2JuPjx1cmxzPjwvdXJs

cz48L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5TY2huZWlkZXI8L0F1dGhvcj48WWVhcj4y

MDEyPC9ZZWFyPjxSZWNOdW0+NjwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+NjwvcmVjLW51

bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0

NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3ODQxOTU3Ij42PC9rZXk+PC9mb3Jl

aWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxj

b250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5TY2huZWlkZXIsIEp1bGllPC9hdXRob3I+PGF1

dGhvcj5Hb3BpbmF0aCwgQmFtaW5pPC9hdXRob3I+PGF1dGhvcj5NY01haG9uLCBDYXRoZXJpbmU8

L2F1dGhvcj48YXV0aG9yPlRlYmVyLCBFcmRhaGw8L2F1dGhvcj48YXV0aG9yPkxlZWRlciwgU3Rl

cGhlbiBSPC9hdXRob3I+PGF1dGhvcj5XYW5nLCBKaWUgSmluPC9hdXRob3I+PGF1dGhvcj5NaXRj

aGVsbCwgUGF1bDwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRs

ZT5QcmV2YWxlbmNlIGFuZCA1LXllYXIgaW5jaWRlbmNlIG9mIGR1YWwgc2Vuc29yeSBpbXBhaXJt

ZW50IGluIGFuIG9sZGVyIEF1c3RyYWxpYW4gcG9wdWxhdGlvbjwvdGl0bGU+PHNlY29uZGFyeS10

aXRsZT5Bbm5hbHMgb2YgZXBpZGVtaW9sb2d5PC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBl

cmlvZGljYWw+PGZ1bGwtdGl0bGU+QW5uYWxzIG9mIGVwaWRlbWlvbG9neTwvZnVsbC10aXRsZT48

L3BlcmlvZGljYWw+PHBhZ2VzPjI5NS0zMDE8L3BhZ2VzPjx2b2x1bWU+MjI8L3ZvbHVtZT48bnVt

YmVyPjQ8L251bWJlcj48ZGF0ZXM+PHllYXI+MjAxMjwveWVhcj48L2RhdGVzPjxpc2JuPjEwNDct

Mjc5NzwvaXNibj48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+Q2Fi

YW48L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFyPjxSZWNOdW0+NzwvUmVjTnVtPjxyZWNvcmQ+PHJl

Yy1udW1iZXI+NzwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9

Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3ODQx

OTU3Ij43PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNs

ZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5DYWJhbiwgQWxi

ZXJ0byBKPC9hdXRob3I+PGF1dGhvcj5MZWUsIERhdmlkIEo8L2F1dGhvcj48YXV0aG9yPkfDs21l

ei1NYXLDrW4sIE9ybGFuZG88L2F1dGhvcj48YXV0aG9yPkxhbSwgQnlyb24gTDwvYXV0aG9yPjxh

dXRob3I+WmhlbmcsIEQgRGlhbmU8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PHRp

dGxlcz48dGl0bGU+UHJldmFsZW5jZSBvZiBjb25jdXJyZW50IGhlYXJpbmcgYW5kIHZpc3VhbCBp

bXBhaXJtZW50IGluIFVTIGFkdWx0czogVGhlIE5hdGlvbmFsIEhlYWx0aCBJbnRlcnZpZXcgU3Vy

dmV5LCAxOTk34oCTMjAwMjwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5BbWVyaWNhbiBKb3VybmFs

IG9mIFB1YmxpYyBIZWFsdGg8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48

ZnVsbC10aXRsZT5BbWVyaWNhbiBKb3VybmFsIG9mIFB1YmxpYyBIZWFsdGg8L2Z1bGwtdGl0bGU+

PC9wZXJpb2RpY2FsPjxwYWdlcz4xOTQwLTE5NDI8L3BhZ2VzPjx2b2x1bWU+OTU8L3ZvbHVtZT48

bnVtYmVyPjExPC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMDU8L3llYXI+PC9kYXRlcz48aXNibj4w

MDkwLTAwMzY8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9y

PkhhcmFkYTwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+PFJlY051bT41PC9SZWNOdW0+PHJlY29y

ZD48cmVjLW51bWJlcj41PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBk

Yi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1

Mjc4NDE5NTciPjU8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBB

cnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkhhcmFk

YSwgU2VpPC9hdXRob3I+PGF1dGhvcj5OaXNoaXdha2ksIFl1amk8L2F1dGhvcj48YXV0aG9yPk1p

Y2hpa2F3YSwgVGFrZWhpcm88L2F1dGhvcj48YXV0aG9yPktpa3VjaGksIFl1cmlrbzwvYXV0aG9y

PjxhdXRob3I+SXdhc2F3YSwgU2F0b2tvPC9hdXRob3I+PGF1dGhvcj5OYWthbm8sIE1ha2lrbzwv

YXV0aG9yPjxhdXRob3I+SXNoaWdhbWksIEFpPC9hdXRob3I+PGF1dGhvcj5TYWl0bywgSGlkZXl1

a2k8L2F1dGhvcj48YXV0aG9yPlRha2ViYXlhc2hpLCBUb3J1PC9hdXRob3I+PC9hdXRob3JzPjwv

Y29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkdlbmRlciBkaWZmZXJlbmNlIGluIHRoZSByZWxh

dGlvbnNoaXBzIGJldHdlZW4gdmlzaW9uIGFuZCBoZWFyaW5nIGltcGFpcm1lbnRzIGFuZCBuZWdh

dGl2ZSB3ZWxsLWJlaW5nPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPlByZXZlbnRpdmUgbWVkaWNp

bmU8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5QcmV2

ZW50aXZlIG1lZGljaW5lPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+NDMzLTQzNzwv

cGFnZXM+PHZvbHVtZT40Nzwvdm9sdW1lPjxudW1iZXI+NDwvbnVtYmVyPjxkYXRlcz48eWVhcj4y

MDA4PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDA5MS03NDM1PC9pc2JuPjx1cmxzPjwvdXJscz48L3Jl

Y29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5DYWJhbjwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+

PFJlY051bT43PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj43PC9yZWMtbnVtYmVyPjxmb3Jl

aWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5

eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTciPjc8L2tleT48L2ZvcmVpZ24ta2V5cz48

cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9y

cz48YXV0aG9ycz48YXV0aG9yPkNhYmFuLCBBbGJlcnRvIEo8L2F1dGhvcj48YXV0aG9yPkxlZSwg

RGF2aWQgSjwvYXV0aG9yPjxhdXRob3I+R8OzbWV6LU1hcsOtbiwgT3JsYW5kbzwvYXV0aG9yPjxh

dXRob3I+TGFtLCBCeXJvbiBMPC9hdXRob3I+PGF1dGhvcj5aaGVuZywgRCBEaWFuZTwvYXV0aG9y

PjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5QcmV2YWxlbmNlIG9mIGNv

bmN1cnJlbnQgaGVhcmluZyBhbmQgdmlzdWFsIGltcGFpcm1lbnQgaW4gVVMgYWR1bHRzOiBUaGUg

TmF0aW9uYWwgSGVhbHRoIEludGVydmlldyBTdXJ2ZXksIDE5OTfigJMyMDAyPC90aXRsZT48c2Vj

b25kYXJ5LXRpdGxlPkFtZXJpY2FuIEpvdXJuYWwgb2YgUHVibGljIEhlYWx0aDwvc2Vjb25kYXJ5

LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkFtZXJpY2FuIEpvdXJuYWwg

b2YgUHVibGljIEhlYWx0aDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjE5NDAtMTk0

MjwvcGFnZXM+PHZvbHVtZT45NTwvdm9sdW1lPjxudW1iZXI+MTE8L251bWJlcj48ZGF0ZXM+PHll

YXI+MjAwNTwveWVhcj48L2RhdGVzPjxpc2JuPjAwOTAtMDAzNjwvaXNibj48dXJscz48L3VybHM+

PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+S2FzdGh1cmk8L0F1dGhvcj48WWVhcj4yMDEy

PC9ZZWFyPjxSZWNOdW0+ODwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+ODwvcmVjLW51bWJl

cj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2

d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3ODQxOTU3Ij44PC9rZXk+PC9mb3JlaWdu

LWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250

cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5LYXN0aHVyaSwgQXJ2aW5kPC9hdXRob3I+PC9hdXRo

b3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPlZpc3VhbCBhbmQgaGVhcmluZyBpbXBh

aXJtZW50IGFtb25nIHJ1cmFsIGVsZGVybHkgb2Ygc291dGggSW5kaWE6IEEgY29tbXVuaXR54oCQ

YmFzZWQgc3R1ZHk8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+R2VyaWF0cmljcyAmYW1wOyBnZXJv

bnRvbG9neSBpbnRlcm5hdGlvbmFsPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGlj

YWw+PGZ1bGwtdGl0bGU+R2VyaWF0cmljcyAmYW1wOyBnZXJvbnRvbG9neSBpbnRlcm5hdGlvbmFs

PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+MTE2LTEyMjwvcGFnZXM+PHZvbHVtZT4x

Mjwvdm9sdW1lPjxudW1iZXI+MTwvbnVtYmVyPjxkYXRlcz48eWVhcj4yMDEyPC95ZWFyPjwvZGF0

ZXM+PGlzYm4+MTQ0Ny0wNTk0PC9pc2JuPjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+PENp

dGU+PEF1dGhvcj5WaWxqYW5lbjwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+PFJlY051bT45PC9S

ZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj45PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtl

eSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0

aW1lc3RhbXA9IjE1Mjc4NDE5NTciPjk8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFt

ZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48

YXV0aG9yPlZpbGphbmVuLCBBbm5lPC9hdXRob3I+PGF1dGhvcj5Uw7ZybcOka2FuZ2FzLCBUaW1v

PC9hdXRob3I+PGF1dGhvcj5WZXN0ZXJnYWFyZCwgU29uamE8L2F1dGhvcj48YXV0aG9yPkFuZGVy

c2VuLVJhbmJlcmcsIEthcmVuPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRs

ZXM+PHRpdGxlPkR1YWwgc2Vuc29yeSBsb3NzIGFuZCBzb2NpYWwgcGFydGljaXBhdGlvbiBpbiBv

bGRlciBFdXJvcGVhbnM8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+RXVyb3BlYW4gSm91cm5hbCBv

ZiBBZ2Vpbmc8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRs

ZT5FdXJvcGVhbiBKb3VybmFsIG9mIEFnZWluZzwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBh

Z2VzPjE1NS0xNjc8L3BhZ2VzPjx2b2x1bWU+MTE8L3ZvbHVtZT48bnVtYmVyPjI8L251bWJlcj48

ZGF0ZXM+PHllYXI+MjAxNDwveWVhcj48L2RhdGVzPjxpc2JuPjE2MTMtOTM3MjwvaXNibj48dXJs

cz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT5=

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2huZWlkZXI8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy

PjxSZWNOdW0+MjwvUmVjTnVtPjxEaXNwbGF5VGV4dD5bMTEsIDEzLTE4XTwvRGlzcGxheVRleHQ+

PHJlY29yZD48cmVjLW51bWJlcj4yPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9

IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3Rh

bXA9IjE1Mjc4NDE5NTciPjI8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91

cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9y

PlNjaG5laWRlciwgSnVsaWUgTTwvYXV0aG9yPjxhdXRob3I+R29waW5hdGgsIEJhbWluaTwvYXV0

aG9yPjxhdXRob3I+TWNNYWhvbiwgQ2F0aGVyaW5lIE08L2F1dGhvcj48YXV0aG9yPkxlZWRlciwg

U3RlcGhlbiBSPC9hdXRob3I+PGF1dGhvcj5NaXRjaGVsbCwgUGF1bDwvYXV0aG9yPjxhdXRob3I+

V2FuZywgSmllIEppbjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0

aXRsZT5EdWFsIHNlbnNvcnkgaW1wYWlybWVudCBpbiBvbGRlciBhZ2U8L3RpdGxlPjxzZWNvbmRh

cnktdGl0bGU+Sm91cm5hbCBvZiBBZ2luZyBhbmQgSGVhbHRoPC9zZWNvbmRhcnktdGl0bGU+PC90

aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+Sm91cm5hbCBvZiBBZ2luZyBhbmQgSGVhbHRo

PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+MTMwOS0xMzI0PC9wYWdlcz48dm9sdW1l

PjIzPC92b2x1bWU+PG51bWJlcj44PC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTE8L3llYXI+PC9k

YXRlcz48aXNibj4wODk4LTI2NDM8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48

Q2l0ZT48QXV0aG9yPkNoaWE8L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFyPjxSZWNOdW0+NDwvUmVj

TnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+NDwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkg

YXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGlt

ZXN0YW1wPSIxNTI3ODQxOTU3Ij40PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9

IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1

dGhvcj5DaGlhLCBFZS1NdW5uPC9hdXRob3I+PGF1dGhvcj5NaXRjaGVsbCwgUGF1bDwvYXV0aG9y

PjxhdXRob3I+Um9jaHRjaGluYSwgRWxlbmE8L2F1dGhvcj48YXV0aG9yPkZvcmFuLCBTdXJpeWE8

L2F1dGhvcj48YXV0aG9yPkdvbGRpbmcsIE1hcnlhbm5lPC9hdXRob3I+PGF1dGhvcj5XYW5nLCBK

aWUgSmluPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkFz

c29jaWF0aW9uIGJldHdlZW4gdmlzaW9uIGFuZCBoZWFyaW5nIGltcGFpcm1lbnRzIGFuZCB0aGVp

ciBjb21iaW5lZCBlZmZlY3RzIG9uIHF1YWxpdHkgb2YgbGlmZTwvdGl0bGU+PHNlY29uZGFyeS10

aXRsZT5BcmNoaXZlcyBvZiBPcGh0aGFsbW9sb2d5PC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+

PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+QXJjaGl2ZXMgb2YgT3BodGhhbG1vbG9neTwvZnVsbC10

aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjE0NjUtMTQ3MDwvcGFnZXM+PHZvbHVtZT4xMjQ8L3Zv

bHVtZT48bnVtYmVyPjEwPC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMDY8L3llYXI+PC9kYXRlcz48

aXNibj4wMDAzLTk5NTA8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48

QXV0aG9yPkhhcmFkYTwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+PFJlY051bT41PC9SZWNOdW0+

PHJlY29yZD48cmVjLW51bWJlcj41PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9

IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3Rh

bXA9IjE1Mjc4NDE5NTciPjU8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91

cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9y

PkhhcmFkYSwgU2VpPC9hdXRob3I+PGF1dGhvcj5OaXNoaXdha2ksIFl1amk8L2F1dGhvcj48YXV0

aG9yPk1pY2hpa2F3YSwgVGFrZWhpcm88L2F1dGhvcj48YXV0aG9yPktpa3VjaGksIFl1cmlrbzwv

YXV0aG9yPjxhdXRob3I+SXdhc2F3YSwgU2F0b2tvPC9hdXRob3I+PGF1dGhvcj5OYWthbm8sIE1h

a2lrbzwvYXV0aG9yPjxhdXRob3I+SXNoaWdhbWksIEFpPC9hdXRob3I+PGF1dGhvcj5TYWl0bywg

SGlkZXl1a2k8L2F1dGhvcj48YXV0aG9yPlRha2ViYXlhc2hpLCBUb3J1PC9hdXRob3I+PC9hdXRo

b3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkdlbmRlciBkaWZmZXJlbmNlIGluIHRo

ZSByZWxhdGlvbnNoaXBzIGJldHdlZW4gdmlzaW9uIGFuZCBoZWFyaW5nIGltcGFpcm1lbnRzIGFu

ZCBuZWdhdGl2ZSB3ZWxsLWJlaW5nPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPlByZXZlbnRpdmUg

bWVkaWNpbmU8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRs

ZT5QcmV2ZW50aXZlIG1lZGljaW5lPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+NDMz

LTQzNzwvcGFnZXM+PHZvbHVtZT40Nzwvdm9sdW1lPjxudW1iZXI+NDwvbnVtYmVyPjxkYXRlcz48

eWVhcj4yMDA4PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDA5MS03NDM1PC9pc2JuPjx1cmxzPjwvdXJs

cz48L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5TY2huZWlkZXI8L0F1dGhvcj48WWVhcj4y

MDEyPC9ZZWFyPjxSZWNOdW0+NjwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+NjwvcmVjLW51

bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0

NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3ODQxOTU3Ij42PC9rZXk+PC9mb3Jl

aWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxj

b250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5TY2huZWlkZXIsIEp1bGllPC9hdXRob3I+PGF1

dGhvcj5Hb3BpbmF0aCwgQmFtaW5pPC9hdXRob3I+PGF1dGhvcj5NY01haG9uLCBDYXRoZXJpbmU8

L2F1dGhvcj48YXV0aG9yPlRlYmVyLCBFcmRhaGw8L2F1dGhvcj48YXV0aG9yPkxlZWRlciwgU3Rl

cGhlbiBSPC9hdXRob3I+PGF1dGhvcj5XYW5nLCBKaWUgSmluPC9hdXRob3I+PGF1dGhvcj5NaXRj

aGVsbCwgUGF1bDwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRs

ZT5QcmV2YWxlbmNlIGFuZCA1LXllYXIgaW5jaWRlbmNlIG9mIGR1YWwgc2Vuc29yeSBpbXBhaXJt

ZW50IGluIGFuIG9sZGVyIEF1c3RyYWxpYW4gcG9wdWxhdGlvbjwvdGl0bGU+PHNlY29uZGFyeS10

aXRsZT5Bbm5hbHMgb2YgZXBpZGVtaW9sb2d5PC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBl

cmlvZGljYWw+PGZ1bGwtdGl0bGU+QW5uYWxzIG9mIGVwaWRlbWlvbG9neTwvZnVsbC10aXRsZT48

L3BlcmlvZGljYWw+PHBhZ2VzPjI5NS0zMDE8L3BhZ2VzPjx2b2x1bWU+MjI8L3ZvbHVtZT48bnVt

YmVyPjQ8L251bWJlcj48ZGF0ZXM+PHllYXI+MjAxMjwveWVhcj48L2RhdGVzPjxpc2JuPjEwNDct

Mjc5NzwvaXNibj48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+Q2Fi

YW48L0F1dGhvcj48WWVhcj4yMDA1PC9ZZWFyPjxSZWNOdW0+NzwvUmVjTnVtPjxyZWNvcmQ+PHJl

Yy1udW1iZXI+NzwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9

Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3ODQx

OTU3Ij43PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNs

ZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5DYWJhbiwgQWxi

ZXJ0byBKPC9hdXRob3I+PGF1dGhvcj5MZWUsIERhdmlkIEo8L2F1dGhvcj48YXV0aG9yPkfDs21l

ei1NYXLDrW4sIE9ybGFuZG88L2F1dGhvcj48YXV0aG9yPkxhbSwgQnlyb24gTDwvYXV0aG9yPjxh

dXRob3I+WmhlbmcsIEQgRGlhbmU8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PHRp

dGxlcz48dGl0bGU+UHJldmFsZW5jZSBvZiBjb25jdXJyZW50IGhlYXJpbmcgYW5kIHZpc3VhbCBp

bXBhaXJtZW50IGluIFVTIGFkdWx0czogVGhlIE5hdGlvbmFsIEhlYWx0aCBJbnRlcnZpZXcgU3Vy

dmV5LCAxOTk34oCTMjAwMjwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5BbWVyaWNhbiBKb3VybmFs

IG9mIFB1YmxpYyBIZWFsdGg8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48

ZnVsbC10aXRsZT5BbWVyaWNhbiBKb3VybmFsIG9mIFB1YmxpYyBIZWFsdGg8L2Z1bGwtdGl0bGU+

PC9wZXJpb2RpY2FsPjxwYWdlcz4xOTQwLTE5NDI8L3BhZ2VzPjx2b2x1bWU+OTU8L3ZvbHVtZT48

bnVtYmVyPjExPC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMDU8L3llYXI+PC9kYXRlcz48aXNibj4w

MDkwLTAwMzY8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9y

PkhhcmFkYTwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+PFJlY051bT41PC9SZWNOdW0+PHJlY29y

ZD48cmVjLW51bWJlcj41PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBk

Yi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1

Mjc4NDE5NTciPjU8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBB

cnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkhhcmFk

YSwgU2VpPC9hdXRob3I+PGF1dGhvcj5OaXNoaXdha2ksIFl1amk8L2F1dGhvcj48YXV0aG9yPk1p

Y2hpa2F3YSwgVGFrZWhpcm88L2F1dGhvcj48YXV0aG9yPktpa3VjaGksIFl1cmlrbzwvYXV0aG9y

PjxhdXRob3I+SXdhc2F3YSwgU2F0b2tvPC9hdXRob3I+PGF1dGhvcj5OYWthbm8sIE1ha2lrbzwv

YXV0aG9yPjxhdXRob3I+SXNoaWdhbWksIEFpPC9hdXRob3I+PGF1dGhvcj5TYWl0bywgSGlkZXl1

a2k8L2F1dGhvcj48YXV0aG9yPlRha2ViYXlhc2hpLCBUb3J1PC9hdXRob3I+PC9hdXRob3JzPjwv

Y29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkdlbmRlciBkaWZmZXJlbmNlIGluIHRoZSByZWxh

dGlvbnNoaXBzIGJldHdlZW4gdmlzaW9uIGFuZCBoZWFyaW5nIGltcGFpcm1lbnRzIGFuZCBuZWdh

dGl2ZSB3ZWxsLWJlaW5nPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPlByZXZlbnRpdmUgbWVkaWNp

bmU8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5QcmV2

ZW50aXZlIG1lZGljaW5lPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+NDMzLTQzNzwv

cGFnZXM+PHZvbHVtZT40Nzwvdm9sdW1lPjxudW1iZXI+NDwvbnVtYmVyPjxkYXRlcz48eWVhcj4y

MDA4PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDA5MS03NDM1PC9pc2JuPjx1cmxzPjwvdXJscz48L3Jl

Y29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5DYWJhbjwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+

PFJlY051bT43PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj43PC9yZWMtbnVtYmVyPjxmb3Jl

aWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5

eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTciPjc8L2tleT48L2ZvcmVpZ24ta2V5cz48

cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9y

cz48YXV0aG9ycz48YXV0aG9yPkNhYmFuLCBBbGJlcnRvIEo8L2F1dGhvcj48YXV0aG9yPkxlZSwg

RGF2aWQgSjwvYXV0aG9yPjxhdXRob3I+R8OzbWV6LU1hcsOtbiwgT3JsYW5kbzwvYXV0aG9yPjxh

dXRob3I+TGFtLCBCeXJvbiBMPC9hdXRob3I+PGF1dGhvcj5aaGVuZywgRCBEaWFuZTwvYXV0aG9y

PjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5QcmV2YWxlbmNlIG9mIGNv

bmN1cnJlbnQgaGVhcmluZyBhbmQgdmlzdWFsIGltcGFpcm1lbnQgaW4gVVMgYWR1bHRzOiBUaGUg

TmF0aW9uYWwgSGVhbHRoIEludGVydmlldyBTdXJ2ZXksIDE5OTfigJMyMDAyPC90aXRsZT48c2Vj

b25kYXJ5LXRpdGxlPkFtZXJpY2FuIEpvdXJuYWwgb2YgUHVibGljIEhlYWx0aDwvc2Vjb25kYXJ5

LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkFtZXJpY2FuIEpvdXJuYWwg

b2YgUHVibGljIEhlYWx0aDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjE5NDAtMTk0

MjwvcGFnZXM+PHZvbHVtZT45NTwvdm9sdW1lPjxudW1iZXI+MTE8L251bWJlcj48ZGF0ZXM+PHll

YXI+MjAwNTwveWVhcj48L2RhdGVzPjxpc2JuPjAwOTAtMDAzNjwvaXNibj48dXJscz48L3VybHM+

PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+S2FzdGh1cmk8L0F1dGhvcj48WWVhcj4yMDEy

PC9ZZWFyPjxSZWNOdW0+ODwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+ODwvcmVjLW51bWJl

cj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2

d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3ODQxOTU3Ij44PC9rZXk+PC9mb3JlaWdu

LWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250

cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5LYXN0aHVyaSwgQXJ2aW5kPC9hdXRob3I+PC9hdXRo

b3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPlZpc3VhbCBhbmQgaGVhcmluZyBpbXBh

aXJtZW50IGFtb25nIHJ1cmFsIGVsZGVybHkgb2Ygc291dGggSW5kaWE6IEEgY29tbXVuaXR54oCQ

YmFzZWQgc3R1ZHk8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+R2VyaWF0cmljcyAmYW1wOyBnZXJv

bnRvbG9neSBpbnRlcm5hdGlvbmFsPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGlj

YWw+PGZ1bGwtdGl0bGU+R2VyaWF0cmljcyAmYW1wOyBnZXJvbnRvbG9neSBpbnRlcm5hdGlvbmFs

PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+MTE2LTEyMjwvcGFnZXM+PHZvbHVtZT4x

Mjwvdm9sdW1lPjxudW1iZXI+MTwvbnVtYmVyPjxkYXRlcz48eWVhcj4yMDEyPC95ZWFyPjwvZGF0

ZXM+PGlzYm4+MTQ0Ny0wNTk0PC9pc2JuPjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+PENp

dGU+PEF1dGhvcj5WaWxqYW5lbjwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+PFJlY051bT45PC9S

ZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj45PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtl

eSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0

aW1lc3RhbXA9IjE1Mjc4NDE5NTciPjk8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFt

ZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48

YXV0aG9yPlZpbGphbmVuLCBBbm5lPC9hdXRob3I+PGF1dGhvcj5Uw7ZybcOka2FuZ2FzLCBUaW1v

PC9hdXRob3I+PGF1dGhvcj5WZXN0ZXJnYWFyZCwgU29uamE8L2F1dGhvcj48YXV0aG9yPkFuZGVy

c2VuLVJhbmJlcmcsIEthcmVuPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRs

ZXM+PHRpdGxlPkR1YWwgc2Vuc29yeSBsb3NzIGFuZCBzb2NpYWwgcGFydGljaXBhdGlvbiBpbiBv

bGRlciBFdXJvcGVhbnM8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+RXVyb3BlYW4gSm91cm5hbCBv

ZiBBZ2Vpbmc8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRs

ZT5FdXJvcGVhbiBKb3VybmFsIG9mIEFnZWluZzwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBh

Z2VzPjE1NS0xNjc8L3BhZ2VzPjx2b2x1bWU+MTE8L3ZvbHVtZT48bnVtYmVyPjI8L251bWJlcj48

ZGF0ZXM+PHllYXI+MjAxNDwveWVhcj48L2RhdGVzPjxpc2JuPjE2MTMtOTM3MjwvaXNibj48dXJs

cz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT5=

ADDIN EN.CITE.DATA [11, 13-18]. For example, a large, general population study of sensory impairments in adults aged 50 years and older in 11 European countries identified a prevalence of 5.9% ADDIN EN.CITE <EndNote><Cite><Author>Viljanen</Author><Year>2014</Year><RecNum>9</RecNum><DisplayText>[18]</DisplayText><record><rec-number>9</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">9</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Viljanen, Anne</author><author>T?rm?kangas, Timo</author><author>Vestergaard, Sonja</author><author>Andersen-Ranberg, Karen</author></authors></contributors><titles><title>Dual sensory loss and social participation in older Europeans</title><secondary-title>European Journal of Ageing</secondary-title></titles><periodical><full-title>European Journal of Ageing</full-title></periodical><pages>155-167</pages><volume>11</volume><number>2</number><dates><year>2014</year></dates><isbn>1613-9372</isbn><urls></urls></record></Cite></EndNote>[18]. While deafblindness is more common among older age groups, deafblindness among children and young adults presents additional implications, for example in terms of education and employment.Figure 4. Prevalence of deafblindness by age-5969056197500-660403642360Figure 5. Prevalence of severe deafblindness by sexFigure 5. Prevalence of severe deafblindness by sexThe prevalence of deafblindness was also found to be slightly higher in women than men in each of the study countries (Figure 5). After accounting for age (given that women generally live longer than men), this finding was statistically significant in all datasets, except Ireland and Uruguay. RecommendationsAdopt, in consultation with persons with deafblindness and their organisations, a consistent definition and measurement of deafblindness, and collect, disaggregate and analyse data, to assess and monitor situation of persons with deafblindness, including through relevant analyses of national datasets using the Washington Group Short Set questions or other methods.Conduct additional research on the issues facing persons with deafblindness, including health status and access to healthcare, social participation and wellbeing, quality of work and education, causes, and age of onset. Undertake impact evaluations of interventions designed to improve inclusion.Persons with deafblindness and povertyWhat does the data say?The majority of studies included in the literature review did not provide evidence on the socio-economic status of people living with deafblindness. In all 11 countries covered by the data analysis, households that included persons with deafblindness were more likely to be in the bottom 40% in terms of socio-economic status compared to households with no members with disabilities (Figure 6). The gap in poverty was most pronounced in Ireland (25.9%), the United States (18.9%), Ghana (16.9%) and Tanzania (17.6%). Differences were statistically significant after adjusting for household characteristics (e.g. size, age structure and location) in all countries, with the exception of Vietnam. Compared to people with other disabilities, persons with deafblindness were statistically more likely to be in the bottom 40% in all countries except Vietnam, Sudan and Tanzania. In Vietnam, households that included members with other disabilities were marginally more likely to be poor in comparison to households that included family members with deafblindness. Figure 6. Proportion of households with persons with deafblindness that are in the bottom 40% in terms of socio-economic status compared to households with people who have other disabilities and households with no members who have disabilitiesIn disaggregating poverty by the age of the household member with deafblindness (<50 years or 50+ years), households including younger adults with deafblindness (under 50 years) were statistically more likely to be living in poverty in five countries (Brazil, South Africa, Vietnam, the United States and Indonesia) (Figure 7). This suggests that younger persons with deafblindness may have a greater impact on the situation of the household.Figure 7. Proportion of households with members with deafblindness living in the bottom 40%, by age of person with deafblindness (<50 years and 50+ years)Inadequate social protectionUnsurprisingly, the survey revealed that high-income countries offer better social protection support in comparison to low and middle-income nations. WFDB members reported that, when programmes are in place to support persons with disabilities, they benefit from them. Whilst issues exist with regards to disability assessment and determination processes, such as the need for two different certificates related to sight and hearing impairments, as outlined in section 1, this does not impede access to benefits. ?Social protectionHigh-incomecountriesLow and middle-income countriesAre the needs of persons with deafblindness adequately covered in national social protection and/or welfare laws and policies?66%27%Are there any social protection or poverty reduction services for persons with deafblindness in your?country?66%45%In low and middle-income countries, as well as some high-income nations, social protection benefit schemes tend to focus on basic poverty-related issues and do not cover the extra costs related to interpretation or mobility challenges. As a result of limited service provision and low social benefits, persons with deafblindness cannot afford the support they need. One of the key issues is that policymakers do not view support services and assistive technology as a ‘fundamental need’, and consider them luxuries in comparison to shelter and food. However, these services are essential for daily living, especially for persons with deafblindness who have high support needs. In addition, the majority of disability and/or welfare benefits are conditioned on the basis of either being labelled incapable to work or on an income threshold. As such, a person with deafblindness seeking to work would not receive support to pay for transport or the extra cost of accommodation, factors that are rarely, if ever, covered by employers.Poverty trap: the impact of disability-related costs on persons with deafblindness and their familiesAn innovative South African study on the extra costs of disability (DSD, 2014) illustrated the significant cost impact of disability for persons with deafblindness and their families. The cost of assistive devices to enable communication, for example, was highest for persons with deafblindness. Personal assistance costs were also among the highest. Considering that, in 2014, the monthly disability grant was R1,340 per month, the majority of persons with deafblindness would not be able to afford such assistance. Consequently, a family member would have to stay at home to support the person, incurring an opportunity cost, which was amongst the highest for all groups of persons with disabilities. The table below outlines the range of costs identified by the study (this list is not exhaustive). Type of costCostsCommentsHuman assistance Paid assistance R6,000-R14,000 per monthFull-time, depending on skill levelFamily memberR0Opportunity cost due to income loss Professional interpreterR2,200 per dayTravelPublic transport Double fareFor the person and his or her assistant or interpreterDriverR7,000 per month Assistive technology Computer R8,000-R32,000Dependent on the type of equipment, e.g. a braille or APICS blind readerSoftwareR0-R6,000NVDA available free of charge; costs incurred for alternative softwareInternet/mobile phoneR600 Source: Hanass-Hancock Jill (2015). Elements of the Financial and Economic Costs of Disability to Households in South Africa. A Pilot Study. National Department of Social Development, Republic of South Africa, Pretoria.RecommendationsDisability determination and eligibility processes should consider persons with deafblindness as a distinct disability group.Disability schemes should take into consideration the significant extra cost of deafblindness, including assistive technology, personal assistance and interpreter-guide services.Persons with deafblindness and workWhat does the data say?Only three studies included in the literature review, two from the United States and one from Denmark, examined access to work amongst persons with deafblindness PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYW1tZXllcjwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+

PFJlY051bT4xNDwvUmVjTnVtPjxEaXNwbGF5VGV4dD5bNCwgMTksIDIwXTwvRGlzcGxheVRleHQ+

PHJlY29yZD48cmVjLW51bWJlcj4xNDwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBw

PSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0

YW1wPSIxNTI3ODQxOTU3Ij4xNDwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJK

b3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRo

b3I+RGFtbWV5ZXIsIEplc3BlcjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0

bGVzPjx0aXRsZT5DaGFyYWN0ZXJpc3RpY3Mgb2YgYSBEYW5pc2ggcG9wdWxhdGlvbiBvZiBhZHVs

dHMgd2l0aCBhY3F1aXJlZCBkZWFmYmxpbmRuZXNzIHJlY2VpdmluZyByZWhhYmlsaXRhdGlvbiBz

ZXJ2aWNlczwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5Ccml0aXNoIEpvdXJuYWwgb2YgVmlzdWFs

IEltcGFpcm1lbnQ8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10

aXRsZT5Ccml0aXNoIEpvdXJuYWwgb2YgVmlzdWFsIEltcGFpcm1lbnQ8L2Z1bGwtdGl0bGU+PC9w

ZXJpb2RpY2FsPjxwYWdlcz4xODktMTk3PC9wYWdlcz48dm9sdW1lPjMxPC92b2x1bWU+PG51bWJl

cj4zPC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTM8L3llYXI+PC9kYXRlcz48aXNibj4wMjY0LTYx

OTY8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPkJyZW5u

YW48L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxSZWNOdW0+MTg8L1JlY051bT48cmVjb3JkPjxy

ZWMtbnVtYmVyPjE4PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1p

ZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4

NDE5NTciPjE4PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0

aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5CcmVubmFu

LCBNYXJrPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPklt

cGFpcm1lbnQgb2YgYm90aCB2aXNpb24gYW5kIGhlYXJpbmcgYW1vbmcgb2xkZXIgYWR1bHRzOiBQ

cmV2YWxlbmNlIGFuZCBpbXBhY3Qgb24gcXVhbGl0eSBvZiBsaWZlPC90aXRsZT48c2Vjb25kYXJ5

LXRpdGxlPkdlbmVyYXRpb25zPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+

PGZ1bGwtdGl0bGU+R2VuZXJhdGlvbnM8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz41

Mi01NjwvcGFnZXM+PHZvbHVtZT4yNzwvdm9sdW1lPjxudW1iZXI+MTwvbnVtYmVyPjxkYXRlcz48

eWVhcj4yMDAzPC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDczOC03ODA2PC9pc2JuPjx1cmxzPjwvdXJs

cz48L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5DbWFyPC9BdXRob3I+PFllYXI+MjAxNzwv

WWVhcj48UmVjTnVtPjE5PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4xOTwvcmVjLW51bWJl

cj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2

d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3ODQxOTU3Ij4xOTwva2V5PjwvZm9yZWln

bi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29u

dHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Q21hciwgSmVubmlmZXIgTDwvYXV0aG9yPjxhdXRo

b3I+TWNEb25uYWxsLCBNaWNoZWxlIEM8L2F1dGhvcj48YXV0aG9yPk1hcmtvc2tpLCBLYXNleSBN

PC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkluLVNjaG9v

bCBQcmVkaWN0b3JzIG9mIFBvc3RzY2hvb2wgRW1wbG95bWVudCBmb3IgWW91dGggV2hvIEFyZSBE

ZWFmLUJsaW5kPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkNhcmVlciBEZXZlbG9wbWVudCBhbmQg

VHJhbnNpdGlvbiBmb3IgRXhjZXB0aW9uYWwgSW5kaXZpZHVhbHM8L3NlY29uZGFyeS10aXRsZT48

L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5DYXJlZXIgRGV2ZWxvcG1lbnQgYW5kIFRy

YW5zaXRpb24gZm9yIEV4Y2VwdGlvbmFsIEluZGl2aWR1YWxzPC9mdWxsLXRpdGxlPjwvcGVyaW9k

aWNhbD48cGFnZXM+MjE2NTE0MzQxNzczNjA1NzwvcGFnZXM+PGRhdGVzPjx5ZWFyPjIwMTc8L3ll

YXI+PC9kYXRlcz48aXNibj4yMTY1LTE0MzQ8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwv

Q2l0ZT48L0VuZE5vdGU+AG==

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYW1tZXllcjwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+

PFJlY051bT4xNDwvUmVjTnVtPjxEaXNwbGF5VGV4dD5bNCwgMTksIDIwXTwvRGlzcGxheVRleHQ+

PHJlY29yZD48cmVjLW51bWJlcj4xNDwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBw

PSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0

YW1wPSIxNTI3ODQxOTU3Ij4xNDwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJK

b3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRo

b3I+RGFtbWV5ZXIsIEplc3BlcjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0

bGVzPjx0aXRsZT5DaGFyYWN0ZXJpc3RpY3Mgb2YgYSBEYW5pc2ggcG9wdWxhdGlvbiBvZiBhZHVs

dHMgd2l0aCBhY3F1aXJlZCBkZWFmYmxpbmRuZXNzIHJlY2VpdmluZyByZWhhYmlsaXRhdGlvbiBz

ZXJ2aWNlczwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5Ccml0aXNoIEpvdXJuYWwgb2YgVmlzdWFs

IEltcGFpcm1lbnQ8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10

aXRsZT5Ccml0aXNoIEpvdXJuYWwgb2YgVmlzdWFsIEltcGFpcm1lbnQ8L2Z1bGwtdGl0bGU+PC9w

ZXJpb2RpY2FsPjxwYWdlcz4xODktMTk3PC9wYWdlcz48dm9sdW1lPjMxPC92b2x1bWU+PG51bWJl

cj4zPC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTM8L3llYXI+PC9kYXRlcz48aXNibj4wMjY0LTYx

OTY8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPkJyZW5u

YW48L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxSZWNOdW0+MTg8L1JlY051bT48cmVjb3JkPjxy

ZWMtbnVtYmVyPjE4PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1p

ZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4

NDE5NTciPjE4PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0

aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5CcmVubmFu

LCBNYXJrPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPklt

cGFpcm1lbnQgb2YgYm90aCB2aXNpb24gYW5kIGhlYXJpbmcgYW1vbmcgb2xkZXIgYWR1bHRzOiBQ

cmV2YWxlbmNlIGFuZCBpbXBhY3Qgb24gcXVhbGl0eSBvZiBsaWZlPC90aXRsZT48c2Vjb25kYXJ5

LXRpdGxlPkdlbmVyYXRpb25zPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+

PGZ1bGwtdGl0bGU+R2VuZXJhdGlvbnM8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz41

Mi01NjwvcGFnZXM+PHZvbHVtZT4yNzwvdm9sdW1lPjxudW1iZXI+MTwvbnVtYmVyPjxkYXRlcz48

eWVhcj4yMDAzPC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDczOC03ODA2PC9pc2JuPjx1cmxzPjwvdXJs

cz48L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5DbWFyPC9BdXRob3I+PFllYXI+MjAxNzwv

WWVhcj48UmVjTnVtPjE5PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4xOTwvcmVjLW51bWJl

cj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2

d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3ODQxOTU3Ij4xOTwva2V5PjwvZm9yZWln

bi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29u

dHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Q21hciwgSmVubmlmZXIgTDwvYXV0aG9yPjxhdXRo

b3I+TWNEb25uYWxsLCBNaWNoZWxlIEM8L2F1dGhvcj48YXV0aG9yPk1hcmtvc2tpLCBLYXNleSBN

PC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkluLVNjaG9v

bCBQcmVkaWN0b3JzIG9mIFBvc3RzY2hvb2wgRW1wbG95bWVudCBmb3IgWW91dGggV2hvIEFyZSBE

ZWFmLUJsaW5kPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkNhcmVlciBEZXZlbG9wbWVudCBhbmQg

VHJhbnNpdGlvbiBmb3IgRXhjZXB0aW9uYWwgSW5kaXZpZHVhbHM8L3NlY29uZGFyeS10aXRsZT48

L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5DYXJlZXIgRGV2ZWxvcG1lbnQgYW5kIFRy

YW5zaXRpb24gZm9yIEV4Y2VwdGlvbmFsIEluZGl2aWR1YWxzPC9mdWxsLXRpdGxlPjwvcGVyaW9k

aWNhbD48cGFnZXM+MjE2NTE0MzQxNzczNjA1NzwvcGFnZXM+PGRhdGVzPjx5ZWFyPjIwMTc8L3ll

YXI+PC9kYXRlcz48aXNibj4yMTY1LTE0MzQ8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwv

Q2l0ZT48L0VuZE5vdGU+AG==

ADDIN EN.CITE.DATA [4, 19, 20]. All found barriers to engaging in employment, although sample sizes were small and not representative of the broader population. Some challenges highlighted included difficulties transitioning from school to work, the need for vocational training ADDIN EN.CITE <EndNote><Cite><Author>Cmar</Author><Year>2017</Year><RecNum>19</RecNum><DisplayText>[20]</DisplayText><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">19</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cmar, Jennifer L</author><author>McDonnall, Michele C</author><author>Markoski, Kasey M</author></authors></contributors><titles><title>In-School Predictors of Postschool Employment for Youth Who Are Deaf-Blind</title><secondary-title>Career Development and Transition for Exceptional Individuals</secondary-title></titles><periodical><full-title>Career Development and Transition for Exceptional Individuals</full-title></periodical><pages>2165143417736057</pages><dates><year>2017</year></dates><isbn>2165-1434</isbn><urls></urls></record></Cite></EndNote>[20], and early retirement following the onset of deafblindness in older age ADDIN EN.CITE <EndNote><Cite><Author>Brennan</Author><Year>2003</Year><RecNum>18</RecNum><DisplayText>[19]</DisplayText><record><rec-number>18</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">18</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Brennan, Mark</author></authors></contributors><titles><title>Impairment of both vision and hearing among older adults: Prevalence and impact on quality of life</title><secondary-title>Generations</secondary-title></titles><periodical><full-title>Generations</full-title></periodical><pages>52-56</pages><volume>27</volume><number>1</number><dates><year>2003</year></dates><isbn>0738-7806</isbn><urls></urls></record></Cite></EndNote>[19].Figure 8 compares the working status of persons with deafblindness, people with other disabilities, and people with no disabilities across the datasets. Specifically, the survey reports on whether or not the respondent has undertaken any work for cash or in-kind payment over the last 12 months. The findings are restricted to persons of working age (15 to 64), excluding those currently in education.Figure 8. Working status of adults (18 years and over) with deafblindness, other disabilities and no disabilities (has worked in the last 12 months, excluding people currently studying)In comparison with people with no disabilities, persons with deafblindness were statistically less likely to be working across all 11 datasets. Participation rates among persons with deafblindness tended to be higher in low-income settings compared with high-income settings. For example, only 23% of adults with deafblindness in Ireland and 29% in the United States were working, compared with 70% and 75% of people without deafblindness respectively. In comparison, gaps in participation rates in Sudan (a gap of 15%) and Ghana (11%) were lower. This trend was inconsistent, however, as high gaps in participation were also evident in Indonesia (55%) and Vietnam (73%). Excluding Uruguay, where the sample size was too low for age-stratified analysis, people with deafblindness across all age groups were statistically less likely to be working than people without disabilities in all datasets except Sudan, where there was no statistical difference in the 15 to 29 age group (see Figure 9 overleaf). In comparison to people without disabilities, the gap in participation appears to increase with age, and is most pronounced amongst older adults in high-income settings. Compared to people with other disabilities, persons with deafblindness were statistically less likely to be working in seven of the eleven datasets (Sudan, Ireland, United States, Vietnam, Indonesia, Tanzania and South Africa), after controlling for age and gender. However, younger people with deafblindness were statistically more likely to be working than younger people with other disabilities in the United States and Brazil, with no statistical differences evident for this age group in other countries. People with deafblindness aged 30 to 49 were statistically less likely to be working than people with other disabilities in Ireland, Tanzania and South Africa, and more likely to be working in Ghana and Brazil. In the oldest group of working age adults (50 to 64), people with deafblindness were less likely to be working than people with other disabilities in Ireland, the United States and South Africa.There were no consistent trends between men with deafblindness and men with other disabilities, but women with deafblindness were less likely to be working than women with other disabilities in seven of the eleven datasets (Sudan, Ireland, United States, Tanzania, South Africa, Indonesia and Brazil).Figure 9. Amongst people of working age who were not working, people with deafblindness were much less likely to be looking for work than people without disabilities, and this was statistically significant in eight of the eleven datasets. People with deafblindness were also statistically less likely to be working than people with other disabilities in three datasets (the United States, Indonesia and Vietnam), and more likely to be looking for work than people with other disabilities in Brazil. It is important to note that this data does not account for work security or type of work. For example, in many low and middle-income countries, the informal economy is the main source of employment. Whilst it is easier to find informal work, employment is typically less stable, lower paid and does not offer protections for workers (e.g. sickness/accident insurance, pensions or representation) ADDIN EN.CITE <EndNote><Cite><Author>International Labour Organisation</Author><Year>2002</Year><RecNum>119</RecNum><DisplayText>[21]</DisplayText><record><rec-number>119</rec-number><foreign-keys><key app="EN" db-id="wz5eaf5a0st2s6e2pec55fs0z9dvftws5pre" timestamp="1527723863">119</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>International Labour Organisation, </author></authors></contributors><titles><title>Women and Men in the Informal Economy: A Statistical Picture</title></titles><dates><year>2002</year></dates><pub-location>Geneva</pub-location><publisher>International Labour Office</publisher><urls></urls></record></Cite></EndNote>[21]. There is evidence that people with disabilities are overall more likely to work in the informal sector ADDIN EN.CITE <EndNote><Cite><Author>International Labour Organisation</Author><Year>2002</Year><RecNum>119</RecNum><DisplayText>[21]</DisplayText><record><rec-number>119</rec-number><foreign-keys><key app="EN" db-id="wz5eaf5a0st2s6e2pec55fs0z9dvftws5pre" timestamp="1527723863">119</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>International Labour Organisation, </author></authors></contributors><titles><title>Women and Men in the Informal Economy: A Statistical Picture</title></titles><dates><year>2002</year></dates><pub-location>Geneva</pub-location><publisher>International Labour Office</publisher><urls></urls></record></Cite></EndNote>[21], which is therefore likely to be similar for persons with deafblindness. Additionally, persons with deafblindness may be less likely to work if they have access to social welfare and benefits. For example, in the study conducted in Denmark, while only 8 of the 163 (5%) people with acquired deafblindness between the ages of 18 and 64 years were employed, 63% were receiving the country’s disability living allowance ADDIN EN.CITE <EndNote><Cite><Author>Dammeyer</Author><Year>2013</Year><RecNum>14</RecNum><DisplayText>[4]</DisplayText><record><rec-number>14</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">14</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dammeyer, Jesper</author></authors></contributors><titles><title>Characteristics of a Danish population of adults with acquired deafblindness receiving rehabilitation services</title><secondary-title>British Journal of Visual Impairment</secondary-title></titles><periodical><full-title>British Journal of Visual Impairment</full-title></periodical><pages>189-197</pages><volume>31</volume><number>3</number><dates><year>2013</year></dates><isbn>0264-6196</isbn><urls></urls></record></Cite></EndNote>[4]. Our voice Employment High-incomecountriesUpper-middle income countriesLow-incomecountriesAre the needs of persons with deafblindness?adequately covered in national employment policy?50%0%9%Are persons with deafblindness receiving support to access employment services?17%34%35%The majority of WFDB members had a negative perspective of the efforts made by governments to ensure equal opportunities to work and employment for persons with deafblindness. Whilst half of all respondents from high-income countries stated that employment policy adequately covers the needs of persons with disabilities, only 17% felt that appropriate employment support measures were in place. Members highlighted discrepancies between policies and implementation. WFDB members from low and middle-income countries stated that employment policies do not really consider persons with deafblindness. However, services do exist to support those in work, especially in relation to livelihood and self-employment. The differences between higher and lower-income countries can be attributed to the fact that employment in lower income countries is typically informal with little social protection support. In high-income countries, however, significant barriers to work exist in a mostly formal labour market. As a result, many persons with deafblindness may receive disability benefits, which are often determined by resource threshold or incapacity to work criteria. Ongoing efforts: Vocational training, self-employment and social participation in IndiaThe recently enacted Rights of Persons with Disabilities Act 2016 includes the provision of a 1% job reservation for persons with multiple disabilities, including persons with deafblindness. Prior to the implementation of the Act, there was no provision for persons with deafblindness; however, it is still too early to measure the impact of these changes. In India, the majority of adults with deafblindness are in self-employment. As such, Sense India and its partner organisations in 22 states across the country have implemented a vocational training programme for young adults with deafblindness. The programme follows multiple avenues. An advocacy and awareness-raising programme for officials has resulted in the Industrial Training Institute (ITI) enrolling young adults with deafblindness on vocational training schemes. At the same time, 90 adults with deafblindness have received training support, coaching and seed money to set up their own income generation activities. Thanks to a network of partner organisations, more than 450 young adults with deafblindness have benefitted from vocational training in either centre or community-based programmes. Vocational training and self-employment contribute also to tackle social isolation. To strengthen this aspect, there is engagement to enhance social participation, with the support of family members and local communities. WFDB members from different countries highlighted several common issues:There is a critical link between education and employment: Scandinavian countries provide a good example of governments investing in high quality education for children with deafblindness. This empowers children, gives them confidence and provides them with the necessary employability skills. In the majority of countries, however, a lack of adequate education, orientation and mobility training, daily living skills for children and young people with pre-lingual and post-lingual deafblindness, severely limits employment opportunities. In addition, few countries offer effective career guidance, internship and job placement services that could build a bridge between education and employment.Prejudices of employers. Attitudes constitute a major barrier for many persons with disabilities, but are magnified as a result of a lack of awareness about the communication requirements of persons with deafblindness. This is compounded by a lack of government support for interpreter-guide services, which may significantly increase the cost faced by employers who hire persons with deafblindness. It is clear that, in countries where governments pay for interpreter-guide services, persons with deafblindness find it easier to gain employment. Quota and tax incentive policies could theoretically help; however, the issues outlined above significantly reduce the potential positive impact. Examples were shared of companies employing persons with deafblindness to achieve tax breaks and subsequently not offering them meaningful work or telling them to stay at home. A lack of recognition of deafblindness as unique disability. This leads to people being excluded from legislation in many countries, such as in Bolivia, where employment law does not mention persons with deafblindness. Often persons with deafblindness are not included in vocational training and employment programmes for other persons with disabilities. Few countries reported that their respective governments were financially supporting interpreter-guide services in the workplace. This significantly reduces the inclusion of persons with deafblindness in the labour market.In a number of countries, persons with deafblindness face restrictions in terms of legal capacity. For example, a bank may require a person with deafblindness to have someone present to sign a contract in order to open a bank account. This limits individuals’ ability to manage their finances and engage in economic activities. A study carried out by Sense International in Peru in 2018 concluded that the main barrier to the employment of persons with disabilities, and persons with deafblindness in particular, is the prejudice of employers and co-workers. The study recommended that work placement measures should not focus on a ‘typical’ job that persons with disabilities could do, but that people are provided with support to find work that matches their profile and aspirations. It also highlighted the importance of the use of ‘internal mentors’ as an effective approach to ensure the sustainability of inclusion. The implementation of Law No. 29524, which recognises deafblindness as a unique disability and mandates the state to promote the training and accreditation of interpreter-guides to support people with deafblindness, was identified by the study as a vital development. The study also recommended the introduction of incentives to encourage companies to do more to include persons with disabilities, in particular persons with deafblindness, since current tax benefits are insufficient and have not made an impact.WFDB members also described a range of interesting practice, such as persons with deafblindness who are in employment offering peer support and mentoring to those looking for work. RecommendationsEnsure that persons with deafblindness are adequately included in employment-related laws, policies and programmes. Ensure the adequate provision of interpreter-guides for work and employment.Ongoing efforts: Peer counselling to support the transition from school to work for young persons with deafblindness in Germany For many young people, the transition from school to working life is impeded by two essential challenges. Firstly, there is a lack of deafblind adult role models. As the majority of young persons with deafblindness grow up in hearing families, they typically struggle to overcome barriers in a hearing and visually-orientated environment. Secondly, young persons with deafblindness may have to cope with emotional challenges and identity issues, which are often inadequately tackled by the formal support programmes offered by organisations. This project (funded by the German Federal Ministry of Labour and Social Affairs and undertaken by the Universities of Cologne and RWTH-Aachen) promotes the integration and reintegration of young persons with deafblindness into the labour market via the support of peer counselling. Successfully included adults with deafblindness are selected as mentors and receive training to become peer counsellors. The mentors are then ’matched’ with young persons with deafblindness (mentees). During the peer counselling sessions, the mentor helps his or her mentee to acknowledge their personal situation and empower them to follow identified career pathways. A key element of the programme is developing people’s self-confidence and independence. The process is supported and monitored by professional coaches. The mentors also signpost young people to relevant opportunities and support, and share their own experiences to inspire and motivate. In our own words: Edgar Reyes (Dominican Republic)2524125354012500“After working for 20 years as director of services of the unit for blind people at the National Library of the Dominican Republic, I applied alongside other professionals without disabilities to become a teacher for secondary level students. It was the first time that a person with deafblindness participated in such an application process. I got 85 points out of 100 as a result.“In October 2015, I started my work as a Spanish and literature teacher with students of 1, 2, and 3 grade at a school named Dr Julio Abreu Cuello in my city (Monte Plata). It was a surprise and bewildering for the staff when I started; however, my interaction with the students and good relationship with the staff led to my fast inclusion within the teachers group.“When I got to know that I successfully passed the application process and got a teaching position, I felt a mix of satisfaction and uncertainty. I asked myself: How will I have good communication with students without disabilities? What will be the attitude of my colleagues? Which strategies will I use so that my disability does not interfere with education, work and the relationship with the students?“In an initial meeting with the director and teachers in the school, I explained the nature and characteristics of deafblindness and said that the disability did not stop me from being a cultural manager, radio, television and written newspaper journalist. I felt that I had the capacity and motivation to take on the challenge of starting as a teacher of teenage students without disabilities, to whom I could also become a concrete example of overcoming barriers and negative attitudes faced by persons with disabilities.“At the beginning of the school year I explained to the students in a clear and simple way that I am a person with deafblindness, asking them to participate in class by speaking clearly and at a high volume. I also asked them to commit to being collaborative with me in activities that are visual, such as checklists, supervision and discipline, management of non-accessible technology, and the use of the board. As a result, I got their active collaboration in a natural and spontaneous way.“The main barriers were actually managing a group of 30 students, planning work in didactic units, managing class resources and mobility around the school. I agreed with the director and coordinator about working with groups of 15 students at a time, even if I had to duplicate my work. For planning, resource management and mobility, I got the support of my colleagues, my students and the administrative staff, who all contributed to my accommodation.“To become a teacher required me to learn a lot, additional effort, creativity and imagination to achieve better communication, which in turn increased my capacities, self-esteem, autonomy, social relationships and security. “The year after, I was assigned to another school named Secundario Madre Ascensión Nicol, and from there inclusion was even faster and easier, and became deeper and deeper.“I think that working in the wider community environment, with the students, families and colleagues, allowed me to show them all the contribution that persons with deafblindness can make. Showing our capacities in daily action means more than presentations and speeches at conferences and in the media.”?Persons with deafblindness and educationWhat does the data say?Excluding Uruguay and Ireland due to the small sample sizes, nine datasets provided evidence on school enrolment amongst children with deafblindness aged 5 to 17 years. Children with deafblindness were statistically less likely to be in school than children without disabilities across each of the datasets, with the biggest gaps in enrolment in Mexico (33% gap), Indonesia (62%) and Vietnam (75%).In eight of the nine datasets considered (excluding Brazil), children with deafblindness were also statistically less likely to be in school than children with other disabilities. The gap in enrolment between children with deafblindness and children with other disabilities was largest in Mexico (15%), Indonesia (15%) and Vietnam (16%). There was no difference in the proportion of girls and boys with deafblindness attending school. 133353110865Figure 10. Educational status of children (aged 5 to 17 years) with deafblindness, children with other disabilities, and children without disabilities0Figure 10. Educational status of children (aged 5 to 17 years) with deafblindness, children with other disabilities, and children without disabilities022288500Of those children aged 5 to 17 who were not enrolled in school, children with deafblindness were less likely to have ever previously been enrolled than children without disabilities in seven of the nine datasets. They were also less likely to have ever been enrolled in school than children with other disabilities in four of the datasets. However, due to the small sample size, some findings have wide confidence intervals and should be interpreted with caution.Figure 11. Adults with deafblindness were less likely to have attended school as children than adults with other disabilities and adults without disabilities in each dataset. After accounting for age and gender (given that adults with deafblindness are likely to be older than adults without disabilities), this finding was still statistically significant in all datasets, with the exception of Mexico and Uruguay, where there was no significant difference between adults with deafblindness and those with other disabilities. Considering that age of onset is likely to have been after the completion of education for many adults with deafblindness, this may be due to adults with lower socio-economic status being less likely to attend school or seek healthcare for functional limitations related to ageing.Figure 12.It is important to note that evidence from the country analyses does not provide an indication of the quality of education children with deafblindness receive. Findings from the literature review, which primarily features studies from the United States, raises concerns regarding the quality of education for children with deafblindness. As deafblindness in children and young adults is rare, most educational professionals receive little, if any, training or support to work with students with deafblindness ADDIN EN.CITE <EndNote><Cite><Author>Bruce</Author><Year>2016</Year><RecNum>21</RecNum><DisplayText>[22, 23]</DisplayText><record><rec-number>21</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">21</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bruce, Susan</author><author>Ferrell, Kay</author><author>Luckner, John L</author></authors></contributors><titles><title>Guidelines for the Administration of Educational Programs for Students Who Are Deaf/Hard of Hearing, Visually Impaired, or Deafblind</title><secondary-title>Journal of the American Academy of Special Education Professionals</secondary-title></titles><periodical><full-title>Journal of the American Academy of Special Education Professionals</full-title></periodical><pages>59</pages><volume>47</volume><dates><year>2016</year></dates><urls></urls></record></Cite><Cite><Author>Nelson</Author><Year>2016</Year><RecNum>22</RecNum><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nelson, Catherine</author><author>Bruce, Susan M</author></authors></contributors><titles><title>Critical Issues in the Lives of Children and Youth Who Are Deafblind</title><secondary-title>American annals of the deaf</secondary-title></titles><periodical><full-title>American annals of the deaf</full-title></periodical><pages>406-411</pages><volume>161</volume><number>4</number><dates><year>2016</year></dates><isbn>1543-0375</isbn><urls></urls></record></Cite></EndNote>[22, 23]. Learners with deafblindness are also a very heterogeneous group, so teaching and learning strategies may vary greatly between individuals. For example, strategies can depend on whether deafblindness is pre-lingual or post-lingual, and the level of hearing and visual impairment ADDIN EN.CITE <EndNote><Cite><Author>Dammeyer</Author><Year>2014</Year><RecNum>1</RecNum><DisplayText>[10]</DisplayText><record><rec-number>1</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">1</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dammeyer, Jesper</author></authors></contributors><titles><title>Deafblindness: a review of the literature</title><secondary-title>Scandinavian journal of public health</secondary-title></titles><periodical><full-title>Scandinavian journal of public health</full-title></periodical><pages>554-562</pages><volume>42</volume><number>7</number><dates><year>2014</year></dates><isbn>1403-4948</isbn><urls></urls></record></Cite></EndNote>[10]. Furthermore, many children and young adults with deafblindness have additional disabilities, which require extra learning support PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OYXRpb25hbCBDZW50cmUgb24gRGVhZi1CbGluZG5lc3M8

L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxSZWNOdW0+MjM8L1JlY051bT48RGlzcGxheVRleHQ+

WzI0LCAyNV08L0Rpc3BsYXlUZXh0PjxyZWNvcmQ+PHJlYy1udW1iZXI+MjM8L3JlYy1udW1iZXI+

PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndk

czdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+MjM8L2tleT48L2ZvcmVpZ24t

a2V5cz48cmVmLXR5cGUgbmFtZT0iUmVwb3J0Ij4yNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48

YXV0aG9ycz48YXV0aG9yPk5hdGlvbmFsIENlbnRyZSBvbiBEZWFmLUJsaW5kbmVzcyw8L2F1dGhv

cj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PHRpdGxlcz48dGl0bGU+VGhlIDIwMTMgTmF0aW9u

YWwgQ2hpbGQgQ291bnQgb2YgQ2hpbGRyZW4gYW5kIFlvdXRoIHdobyBhcmUgRGVhZi1CbGluZDwv

dGl0bGU+PC90aXRsZXM+PGRhdGVzPjx5ZWFyPjIwMTQ8L3llYXI+PC9kYXRlcz48dXJscz48L3Vy

bHM+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+V2l0dGljaDwvQXV0aG9yPjxZZWFyPjIw

MTI8L1llYXI+PFJlY051bT4yNDwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+MjQ8L3JlYy1u

dW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3

dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+MjQ8L2tleT48L2Zv

cmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+

PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPldpdHRpY2gsIFcuPC9hdXRob3I+PGF1dGhv

cj5XYXRhbmFiZSwgRC4gSC48L2F1dGhvcj48YXV0aG9yPkdhZ25lLCBKLiBQLjwvYXV0aG9yPjwv

YXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPkNlbnRyZSBkZSByZWNoZXJjaGUg

aW5zdGl0dXQgdW5pdmVyc2l0YWlyZSBkZSBnZXJpYXRyaWUgZGUgTW9udHJlYWwsIE1vbnRyZWFs

IE1BQi1NYWNrYXkgUmVoYWJpbGl0YXRpb24gQ2VudHJlLCBNb250cmVhbCwgQ2FuYWRhLiB3d2l0

dGljaEBzc3NzLmdvdXYucWMuY2E8L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5TZW5zb3J5

IGFuZCBkZW1vZ3JhcGhpYyBjaGFyYWN0ZXJpc3RpY3Mgb2YgZGVhZmJsaW5kbmVzcyByZWhhYmls

aXRhdGlvbiBjbGllbnRzIGluIE1vbnRyZWFsLCBDYW5hZGE8L3RpdGxlPjxzZWNvbmRhcnktdGl0

bGU+T3BodGhhbG1pYyBQaHlzaW9sIE9wdDwvc2Vjb25kYXJ5LXRpdGxlPjxhbHQtdGl0bGU+T3Bo

dGhhbG1pYyAmYW1wOyBwaHlzaW9sb2dpY2FsIG9wdGljcyA6IHRoZSBqb3VybmFsIG9mIHRoZSBC

cml0aXNoIENvbGxlZ2Ugb2YgT3BodGhhbG1pYyBPcHRpY2lhbnMgKE9wdG9tZXRyaXN0cyk8L2Fs

dC10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5PcGh0aGFsbWljIFBoeXNp

b2wgT3B0PC9mdWxsLXRpdGxlPjxhYmJyLTE+T3BodGhhbG1pYyAmYW1wOyBwaHlzaW9sb2dpY2Fs

IG9wdGljcyA6IHRoZSBqb3VybmFsIG9mIHRoZSBCcml0aXNoIENvbGxlZ2Ugb2YgT3BodGhhbG1p

YyBPcHRpY2lhbnMgKE9wdG9tZXRyaXN0cyk8L2FiYnItMT48L3BlcmlvZGljYWw+PGFsdC1wZXJp

b2RpY2FsPjxmdWxsLXRpdGxlPk9waHRoYWxtaWMgUGh5c2lvbCBPcHQ8L2Z1bGwtdGl0bGU+PGFi

YnItMT5PcGh0aGFsbWljICZhbXA7IHBoeXNpb2xvZ2ljYWwgb3B0aWNzIDogdGhlIGpvdXJuYWwg

b2YgdGhlIEJyaXRpc2ggQ29sbGVnZSBvZiBPcGh0aGFsbWljIE9wdGljaWFucyAoT3B0b21ldHJp

c3RzKTwvYWJici0xPjwvYWx0LXBlcmlvZGljYWw+PHBhZ2VzPjI0Mi01MTwvcGFnZXM+PHZvbHVt

ZT4zMjwvdm9sdW1lPjxudW1iZXI+MzwvbnVtYmVyPjxlZGl0aW9uPjIwMTIvMDIvMjI8L2VkaXRp

b24+PGtleXdvcmRzPjxrZXl3b3JkPkFkb2xlc2NlbnQ8L2tleXdvcmQ+PGtleXdvcmQ+QWR1bHQ8

L2tleXdvcmQ+PGtleXdvcmQ+QWdlIERpc3RyaWJ1dGlvbjwva2V5d29yZD48a2V5d29yZD5BZ2Vk

PC9rZXl3b3JkPjxrZXl3b3JkPkFnZWQsIDgwIGFuZCBvdmVyPC9rZXl3b3JkPjxrZXl3b3JkPkF1

ZGl0b3J5IFRocmVzaG9sZC9waHlzaW9sb2d5PC9rZXl3b3JkPjxrZXl3b3JkPkNoaWxkPC9rZXl3

b3JkPjxrZXl3b3JkPkNoaWxkLCBQcmVzY2hvb2w8L2tleXdvcmQ+PGtleXdvcmQ+RGVhZi1CbGlu

ZCBEaXNvcmRlcnMvZXBpZGVtaW9sb2d5L3BoeXNpb3BhdGhvbG9neS8qcmVoYWJpbGl0YXRpb248

L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29y

ZD48a2V5d29yZD5JbmZhbnQ8L2tleXdvcmQ+PGtleXdvcmQ+TWFjdWxhciBEZWdlbmVyYXRpb24v

ZXBpZGVtaW9sb2d5L3BoeXNpb3BhdGhvbG9neS9yZWhhYmlsaXRhdGlvbjwva2V5d29yZD48a2V5

d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3JkPk1pZGRsZSBBZ2VkPC9rZXl3b3JkPjxrZXl3b3Jk

PlByZXNieWN1c2lzL2VwaWRlbWlvbG9neS9waHlzaW9wYXRob2xvZ3kvcmVoYWJpbGl0YXRpb248

L2tleXdvcmQ+PGtleXdvcmQ+UHJldmFsZW5jZTwva2V5d29yZD48a2V5d29yZD5RdWViZWMvZXBp

ZGVtaW9sb2d5PC9rZXl3b3JkPjxrZXl3b3JkPlNleCBEaXN0cmlidXRpb248L2tleXdvcmQ+PGtl

eXdvcmQ+VXNoZXIgU3luZHJvbWVzL2VwaWRlbWlvbG9neS9waHlzaW9wYXRob2xvZ3kvcmVoYWJp

bGl0YXRpb248L2tleXdvcmQ+PGtleXdvcmQ+VmlzdWFsIEFjdWl0eS9waHlzaW9sb2d5PC9rZXl3

b3JkPjxrZXl3b3JkPlZpc3VhbCBGaWVsZHMvcGh5c2lvbG9neTwva2V5d29yZD48a2V5d29yZD5Z

b3VuZyBBZHVsdDwva2V5d29yZD48L2tleXdvcmRzPjxkYXRlcz48eWVhcj4yMDEyPC95ZWFyPjxw

dWItZGF0ZXM+PGRhdGU+TWF5PC9kYXRlPjwvcHViLWRhdGVzPjwvZGF0ZXM+PGlzYm4+MDI3NS01

NDA4PC9pc2JuPjxhY2Nlc3Npb24tbnVtPjIyMzQ4NjUxPC9hY2Nlc3Npb24tbnVtPjx1cmxzPjwv

dXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+MTAuMTExMS9qLjE0NzUtMTMxMy4yMDEyLjAw

ODk3Lng8L2VsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjxyZW1vdGUtZGF0YWJhc2UtcHJvdmlkZXI+

TkxNPC9yZW1vdGUtZGF0YWJhc2UtcHJvdmlkZXI+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+PC9y

ZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT5=

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5OYXRpb25hbCBDZW50cmUgb24gRGVhZi1CbGluZG5lc3M8

L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxSZWNOdW0+MjM8L1JlY051bT48RGlzcGxheVRleHQ+

WzI0LCAyNV08L0Rpc3BsYXlUZXh0PjxyZWNvcmQ+PHJlYy1udW1iZXI+MjM8L3JlYy1udW1iZXI+

PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndk

czdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+MjM8L2tleT48L2ZvcmVpZ24t

a2V5cz48cmVmLXR5cGUgbmFtZT0iUmVwb3J0Ij4yNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48

YXV0aG9ycz48YXV0aG9yPk5hdGlvbmFsIENlbnRyZSBvbiBEZWFmLUJsaW5kbmVzcyw8L2F1dGhv

cj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PHRpdGxlcz48dGl0bGU+VGhlIDIwMTMgTmF0aW9u

YWwgQ2hpbGQgQ291bnQgb2YgQ2hpbGRyZW4gYW5kIFlvdXRoIHdobyBhcmUgRGVhZi1CbGluZDwv

dGl0bGU+PC90aXRsZXM+PGRhdGVzPjx5ZWFyPjIwMTQ8L3llYXI+PC9kYXRlcz48dXJscz48L3Vy

bHM+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+V2l0dGljaDwvQXV0aG9yPjxZZWFyPjIw

MTI8L1llYXI+PFJlY051bT4yNDwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+MjQ8L3JlYy1u

dW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3

dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+MjQ8L2tleT48L2Zv

cmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+

PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPldpdHRpY2gsIFcuPC9hdXRob3I+PGF1dGhv

cj5XYXRhbmFiZSwgRC4gSC48L2F1dGhvcj48YXV0aG9yPkdhZ25lLCBKLiBQLjwvYXV0aG9yPjwv

YXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNzPkNlbnRyZSBkZSByZWNoZXJjaGUg

aW5zdGl0dXQgdW5pdmVyc2l0YWlyZSBkZSBnZXJpYXRyaWUgZGUgTW9udHJlYWwsIE1vbnRyZWFs

IE1BQi1NYWNrYXkgUmVoYWJpbGl0YXRpb24gQ2VudHJlLCBNb250cmVhbCwgQ2FuYWRhLiB3d2l0

dGljaEBzc3NzLmdvdXYucWMuY2E8L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5TZW5zb3J5

IGFuZCBkZW1vZ3JhcGhpYyBjaGFyYWN0ZXJpc3RpY3Mgb2YgZGVhZmJsaW5kbmVzcyByZWhhYmls

aXRhdGlvbiBjbGllbnRzIGluIE1vbnRyZWFsLCBDYW5hZGE8L3RpdGxlPjxzZWNvbmRhcnktdGl0

bGU+T3BodGhhbG1pYyBQaHlzaW9sIE9wdDwvc2Vjb25kYXJ5LXRpdGxlPjxhbHQtdGl0bGU+T3Bo

dGhhbG1pYyAmYW1wOyBwaHlzaW9sb2dpY2FsIG9wdGljcyA6IHRoZSBqb3VybmFsIG9mIHRoZSBC

cml0aXNoIENvbGxlZ2Ugb2YgT3BodGhhbG1pYyBPcHRpY2lhbnMgKE9wdG9tZXRyaXN0cyk8L2Fs

dC10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5PcGh0aGFsbWljIFBoeXNp

b2wgT3B0PC9mdWxsLXRpdGxlPjxhYmJyLTE+T3BodGhhbG1pYyAmYW1wOyBwaHlzaW9sb2dpY2Fs

IG9wdGljcyA6IHRoZSBqb3VybmFsIG9mIHRoZSBCcml0aXNoIENvbGxlZ2Ugb2YgT3BodGhhbG1p

YyBPcHRpY2lhbnMgKE9wdG9tZXRyaXN0cyk8L2FiYnItMT48L3BlcmlvZGljYWw+PGFsdC1wZXJp

b2RpY2FsPjxmdWxsLXRpdGxlPk9waHRoYWxtaWMgUGh5c2lvbCBPcHQ8L2Z1bGwtdGl0bGU+PGFi

YnItMT5PcGh0aGFsbWljICZhbXA7IHBoeXNpb2xvZ2ljYWwgb3B0aWNzIDogdGhlIGpvdXJuYWwg

b2YgdGhlIEJyaXRpc2ggQ29sbGVnZSBvZiBPcGh0aGFsbWljIE9wdGljaWFucyAoT3B0b21ldHJp

c3RzKTwvYWJici0xPjwvYWx0LXBlcmlvZGljYWw+PHBhZ2VzPjI0Mi01MTwvcGFnZXM+PHZvbHVt

ZT4zMjwvdm9sdW1lPjxudW1iZXI+MzwvbnVtYmVyPjxlZGl0aW9uPjIwMTIvMDIvMjI8L2VkaXRp

b24+PGtleXdvcmRzPjxrZXl3b3JkPkFkb2xlc2NlbnQ8L2tleXdvcmQ+PGtleXdvcmQ+QWR1bHQ8

L2tleXdvcmQ+PGtleXdvcmQ+QWdlIERpc3RyaWJ1dGlvbjwva2V5d29yZD48a2V5d29yZD5BZ2Vk

PC9rZXl3b3JkPjxrZXl3b3JkPkFnZWQsIDgwIGFuZCBvdmVyPC9rZXl3b3JkPjxrZXl3b3JkPkF1

ZGl0b3J5IFRocmVzaG9sZC9waHlzaW9sb2d5PC9rZXl3b3JkPjxrZXl3b3JkPkNoaWxkPC9rZXl3

b3JkPjxrZXl3b3JkPkNoaWxkLCBQcmVzY2hvb2w8L2tleXdvcmQ+PGtleXdvcmQ+RGVhZi1CbGlu

ZCBEaXNvcmRlcnMvZXBpZGVtaW9sb2d5L3BoeXNpb3BhdGhvbG9neS8qcmVoYWJpbGl0YXRpb248

L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxrZXl3b3JkPkh1bWFuczwva2V5d29y

ZD48a2V5d29yZD5JbmZhbnQ8L2tleXdvcmQ+PGtleXdvcmQ+TWFjdWxhciBEZWdlbmVyYXRpb24v

ZXBpZGVtaW9sb2d5L3BoeXNpb3BhdGhvbG9neS9yZWhhYmlsaXRhdGlvbjwva2V5d29yZD48a2V5

d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3JkPk1pZGRsZSBBZ2VkPC9rZXl3b3JkPjxrZXl3b3Jk

PlByZXNieWN1c2lzL2VwaWRlbWlvbG9neS9waHlzaW9wYXRob2xvZ3kvcmVoYWJpbGl0YXRpb248

L2tleXdvcmQ+PGtleXdvcmQ+UHJldmFsZW5jZTwva2V5d29yZD48a2V5d29yZD5RdWViZWMvZXBp

ZGVtaW9sb2d5PC9rZXl3b3JkPjxrZXl3b3JkPlNleCBEaXN0cmlidXRpb248L2tleXdvcmQ+PGtl

eXdvcmQ+VXNoZXIgU3luZHJvbWVzL2VwaWRlbWlvbG9neS9waHlzaW9wYXRob2xvZ3kvcmVoYWJp

bGl0YXRpb248L2tleXdvcmQ+PGtleXdvcmQ+VmlzdWFsIEFjdWl0eS9waHlzaW9sb2d5PC9rZXl3

b3JkPjxrZXl3b3JkPlZpc3VhbCBGaWVsZHMvcGh5c2lvbG9neTwva2V5d29yZD48a2V5d29yZD5Z

b3VuZyBBZHVsdDwva2V5d29yZD48L2tleXdvcmRzPjxkYXRlcz48eWVhcj4yMDEyPC95ZWFyPjxw

dWItZGF0ZXM+PGRhdGU+TWF5PC9kYXRlPjwvcHViLWRhdGVzPjwvZGF0ZXM+PGlzYm4+MDI3NS01

NDA4PC9pc2JuPjxhY2Nlc3Npb24tbnVtPjIyMzQ4NjUxPC9hY2Nlc3Npb24tbnVtPjx1cmxzPjwv

dXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+MTAuMTExMS9qLjE0NzUtMTMxMy4yMDEyLjAw

ODk3Lng8L2VsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjxyZW1vdGUtZGF0YWJhc2UtcHJvdmlkZXI+

TkxNPC9yZW1vdGUtZGF0YWJhc2UtcHJvdmlkZXI+PGxhbmd1YWdlPmVuZzwvbGFuZ3VhZ2U+PC9y

ZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT5=

ADDIN EN.CITE.DATA [24, 25]. Early identification and referral to programmes for infants and young children with deafblindness is essential for improving educational, as well as cognitive and social, outcomes ADDIN EN.CITE <EndNote><Cite><Author>National Centre on Deaf-Blindness</Author><Year>2014</Year><RecNum>23</RecNum><DisplayText>[24, 26]</DisplayText><record><rec-number>23</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">23</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>National Centre on Deaf-Blindness,</author></authors></contributors><titles><title>The 2013 National Child Count of Children and Youth who are Deaf-Blind</title></titles><dates><year>2014</year></dates><urls></urls></record></Cite><Cite><Author>Purvis</Author><Year>2014</Year><RecNum>25</RecNum><record><rec-number>25</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">25</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Purvis, Barbara</author><author>Malloy, Peggy</author><author>Schalock, Mark</author><author>McNulty, Kathy</author><author>Davies, Steven</author><author>Stremel-Thomas, Kathleen</author><author>Udell, Tom</author></authors></contributors><titles><title>Early Identificationand Referral of Infants Who Are Deaf-Blind</title></titles><dates><year>2014</year></dates><publisher>National Center on Deaf-Blindness</publisher><urls></urls></record></Cite></EndNote>[24, 26]. However, delays in accessing services are common. For example, across different states in the United States, only 0-26% of children with deafblindness were referred to appropriate services before the age of three ADDIN EN.CITE <EndNote><Cite><Author>Purvis</Author><Year>2014</Year><RecNum>25</RecNum><DisplayText>[26]</DisplayText><record><rec-number>25</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">25</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Purvis, Barbara</author><author>Malloy, Peggy</author><author>Schalock, Mark</author><author>McNulty, Kathy</author><author>Davies, Steven</author><author>Stremel-Thomas, Kathleen</author><author>Udell, Tom</author></authors></contributors><titles><title>Early Identificationand Referral of Infants Who Are Deaf-Blind</title></titles><dates><year>2014</year></dates><publisher>National Center on Deaf-Blindness</publisher><urls></urls></record></Cite></EndNote>[26]. These issues are likely to be even more pronounced in low and middle-income settings where there has been less investment in inclusive education. Our voice EducationHigh-incomecountriesLow and middle-income countriesAre the needs of persons with deafblindness?adequately covered in national education laws and policies?44%18%co-existence of inclusive and special education55%55%Access to special education only33%45%Education is a key issue for WFDB members. They identified strong links between employability, social participation and the educational opportunities accessible to children and young persons with deafblindness. Whilst the situation is more pronounced in low-income countries, less than half of the respondents from high-income countries consider education policies to adequately cover the needs of children with deafblindness. In more than half of the countries included within this study, governments provide a mix of special and inclusive education. A third of high-income countries, and nearly half of lower income countries, however, only provide special education.In our own words: German Guerrero, Colombia“I started to lose my vision around 10 years old and, by the time I was 14, I had lost all my sight. My family tried various solutions until a doctor told me the best ‘medicine’ was education! So then our focus shifted to integration into daily life. “I tried to go to a regular school close to home, but as my sight deteriorated, I found I couldn’t see the chalk board. The doctor advised me to go to the Institute for the Blind to continue with my education. After primary school, I went to a secondary school where I encountered many obstacles. As I had relatives in the United States, my family decided to send me there for better education opportunities. I got a secondary education through an open programme with exams every six months and I started studying music – but then I realised I was losing my hearing. It was a difficult time. However, I then got to meet the Association of People with Deafblindness. “In 2009, the CRPD came into force in Colombia. The National Council for People with Disabilities started to contribute to the implementation of the CRPD. Article 24 references deafblindness and the provision of inclusive high quality education for everyone.“In Colombia, when I was young and growing up it was very difficult. Now there are more laws and regulations to enable inclusive education. Deafblindness is recognised as a unique disability. Around 350 schools now have a model of inclusive education. We have guidelines about enabling children with deafblindness to attend regular schools and be part of regular classes. “However, there’s still more work to do. The education system is not yet providing inclusive, high quality education for all. Most schools are not yet accessible, curricula are not adapted, teachers do not receive training to support people with deafblindness, and there is a lack of interpreter-guides. Decision-makers don’t really understand what people with deafblindness want and need, and don’t commit resources to support them. There is a National Council for People with Disabilities and a liaison group through which we, as deafblind leaders, work to tell the government what is required to fully implement the law. “No-one should suffer what I suffered in the past. Everyone should have access to an inclusive education and, as deafblind leaders, we have to keep working to make the right to an education a reality in our countries. This is because education is the key to independence and to fighting for other rights. The CRPD must be well implemented, which means: adapting the school curricula; making schools accessible; increasing teacher training on working with people with deafblindness; and increasing access to interpreter-guides. Discussions that took place during the 2018 Helen Keller World Conference highlighted several issues:In many countries, a lack of awareness about deafblindness results in both families and institutions failing to recognise the right of children with deafblindness to go to school, and that education obligations apply to all children, regardless of disability. A lack of early identification and intervention programmes means that parents do not learn to communicate with their children. This makes it more difficult for parents to understand and accept their child’s disability, as well as to access support. This, in turn, impacts on a child’s development. In the majority of countries, there is limited data on the numbers of children with deafblindness in or out of school. In many countries, there are no specific educational support programmes for children and young people with deafblindness. Indeed, the majority of support initiatives are either only for deaf or blind children. Teachers are not adequately trained and there is no adaptation of curricula. Members referenced numerous education policies that did not consider children with deafblindness. Existing schools for blind or deaf children may or may not support children with deafblindness; however, there is no systematic approach.While specific support services might be available in some high-income countries, these opportunities are unlikely to be available in the majority of low and middle-income countries. There are also discrepancies within countries, with services predominantly concentrated in the capital or major cities, but not in rural areas or smaller towns.The importance of developing formal and non-formal education services for young people and adults with deafblindness who did not have access to educational opportunities as children. Whilst the vast majority of WFDB members support and are in favour of inclusive education, many also call for the further development of resource centres for children with deafblindness, which provide communication, mobility and daily living skills, and prepare children for school. In some countries, resource centres collaborate with mainstream schools and support teachers who have pupils with deafblindness, training them in communication and pedagogy adaptation. Community-based programmes also provide initial support to children in their homes to prepare them for school and to raise awareness and confidence amongst parents. WFDB members insisted on the importance of developing links between schools, families and communities to ensure the inclusion of children with deafblindness. It was also suggested that, in some countries, it might be easier to obtain adequate support in private schools rather than public sector institutions, which increases the inequalities faced by poorer families.Focus on India: Significant steps towards inclusion but children with deafblindness are missing outIndia is often considered a good example of a country seeking to develop public policies aimed at including children with disabilities in primary and secondary schools. The country’s education policy covers the inclusion of ‘all’ children, including those with deafblindness (6 to 18-years-old), and there are approximately 55,000 children with deafblindness enrolled under the government’s inclusive education programme. The government-provided school system is free to all, and a specific programme covers aids and appliances, nutrition and occasional access to personalised assistance. The issue however is that as in many other countries such as Colombia, inclusive approach has yet not foster adequate training for education staff and curricula are yet to be truly inclusive. To tackle this issue, Sense India has worked in partnership with the Ministry of Human Resource Development and the World Bank to develop guidelines on curriculum adaptation to support mainstream teachers to adapt existing curricula to benefit children with deafblindness. In addition to public schools, a number of privately run mainstream schools with resource centres to support the needs of children with disabilities, including deafblindness, exist across India. These centres also enable adults with deafblindness to access higher education and vocational training programmes.Despite these developments, children with deafblindness are still primarily supported by NGOs through day care and community-based programmes. RecommendationsEnsure that the requirements of persons with deafblindness are taken into account in inclusive education laws, policies and programmes, and efforts are made to adapt curricula, train teachers and provide support to students.Ensure the availability of resource centres that support mainstream schools, children with deafblindness and their families.Ensure the adequate provision of interpreter-guides.Ongoing efforts: Early identification and intervention in RomaniaBy the time children with deafblindness reach school age, it is often too late for them to make significant progress in their development and rehabilitation, which can dramatically affect their learning, communication and socialisation.In 2007, teachers in Romania raised this issue, and Sense International Romania developed a programme to adequately identify deafblindness in babies. These children would then be referred to early intervention services as early as possible so that they could benefit from sensory stimulation therapies, which ultimately improve development, learning and independence.Partnerships were developed with local child welfare authorities, schools and hospitals in four locations across the country. Nationally, and in partnership with the Ministry of Education, an early intervention curriculum was developed and approved, describing the pathway from the hearing screening and visual testing of babies to specific sensory stimulation therapies.Multidisciplinary teams were formed and trained, consisting of special education teachers, psychologists, social workers, physiotherapists, ophthalmologists, neonatologists and audiologists. Parents were also key members of the team, delivering early intervention to their children. Babies at risk of deafblindness underwent hearing screening and visual testing. Children referred to early intervention support centres would benefit from multisensory stimulation, functional visual training, perceptive hearing education, speech therapy and physiotherapy, while parents benefited from information, support and counselling. The children were at the centre of the programme and an individualised intervention plan was tailored to the requirements of each child. A national legal framework was developed for early identification and intervention to be fully embedded in the Romanian education system so that this pilot can be scaled up. It is currently in the process of being approved by the government.Persons with deafblindness and healthWhat does the data say?The country analyses provided little data on health status and access to healthcare. The only indicator of health status was the presence of additional disabilities. Figure 9 shows the proportion of persons with deafblindness with other functional difficulties in each dataset. Between 20% and 75% of persons with deafblindness reported functional difficulties, such as mobility and cognition, and the presence of other functional difficulties remained high across all age groups, including children. Multi-morbidity among children and adults with deafblindness was also reflected in the literature review. For example, among children with deafblindness in Montreal, Canada, 86% had additional disabilities PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XaXR0aWNoPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48

UmVjTnVtPjI0PC9SZWNOdW0+PERpc3BsYXlUZXh0PlsyNV08L0Rpc3BsYXlUZXh0PjxyZWNvcmQ+

PHJlYy1udW1iZXI+MjQ8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRi

LWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUy

Nzg0MTk1NyI+MjQ8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBB

cnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPldpdHRp

Y2gsIFcuPC9hdXRob3I+PGF1dGhvcj5XYXRhbmFiZSwgRC4gSC48L2F1dGhvcj48YXV0aG9yPkdh

Z25lLCBKLiBQLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNz

PkNlbnRyZSBkZSByZWNoZXJjaGUgaW5zdGl0dXQgdW5pdmVyc2l0YWlyZSBkZSBnZXJpYXRyaWUg

ZGUgTW9udHJlYWwsIE1vbnRyZWFsIE1BQi1NYWNrYXkgUmVoYWJpbGl0YXRpb24gQ2VudHJlLCBN

b250cmVhbCwgQ2FuYWRhLiB3d2l0dGljaEBzc3NzLmdvdXYucWMuY2E8L2F1dGgtYWRkcmVzcz48

dGl0bGVzPjx0aXRsZT5TZW5zb3J5IGFuZCBkZW1vZ3JhcGhpYyBjaGFyYWN0ZXJpc3RpY3Mgb2Yg

ZGVhZmJsaW5kbmVzcyByZWhhYmlsaXRhdGlvbiBjbGllbnRzIGluIE1vbnRyZWFsLCBDYW5hZGE8

L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+T3BodGhhbG1pYyBQaHlzaW9sIE9wdDwvc2Vjb25kYXJ5

LXRpdGxlPjxhbHQtdGl0bGU+T3BodGhhbG1pYyAmYW1wOyBwaHlzaW9sb2dpY2FsIG9wdGljcyA6

IHRoZSBqb3VybmFsIG9mIHRoZSBCcml0aXNoIENvbGxlZ2Ugb2YgT3BodGhhbG1pYyBPcHRpY2lh

bnMgKE9wdG9tZXRyaXN0cyk8L2FsdC10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10

aXRsZT5PcGh0aGFsbWljIFBoeXNpb2wgT3B0PC9mdWxsLXRpdGxlPjxhYmJyLTE+T3BodGhhbG1p

YyAmYW1wOyBwaHlzaW9sb2dpY2FsIG9wdGljcyA6IHRoZSBqb3VybmFsIG9mIHRoZSBCcml0aXNo

IENvbGxlZ2Ugb2YgT3BodGhhbG1pYyBPcHRpY2lhbnMgKE9wdG9tZXRyaXN0cyk8L2FiYnItMT48

L3BlcmlvZGljYWw+PGFsdC1wZXJpb2RpY2FsPjxmdWxsLXRpdGxlPk9waHRoYWxtaWMgUGh5c2lv

bCBPcHQ8L2Z1bGwtdGl0bGU+PGFiYnItMT5PcGh0aGFsbWljICZhbXA7IHBoeXNpb2xvZ2ljYWwg

b3B0aWNzIDogdGhlIGpvdXJuYWwgb2YgdGhlIEJyaXRpc2ggQ29sbGVnZSBvZiBPcGh0aGFsbWlj

IE9wdGljaWFucyAoT3B0b21ldHJpc3RzKTwvYWJici0xPjwvYWx0LXBlcmlvZGljYWw+PHBhZ2Vz

PjI0Mi01MTwvcGFnZXM+PHZvbHVtZT4zMjwvdm9sdW1lPjxudW1iZXI+MzwvbnVtYmVyPjxlZGl0

aW9uPjIwMTIvMDIvMjI8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFkb2xlc2NlbnQ8L2tl

eXdvcmQ+PGtleXdvcmQ+QWR1bHQ8L2tleXdvcmQ+PGtleXdvcmQ+QWdlIERpc3RyaWJ1dGlvbjwv

a2V5d29yZD48a2V5d29yZD5BZ2VkPC9rZXl3b3JkPjxrZXl3b3JkPkFnZWQsIDgwIGFuZCBvdmVy

PC9rZXl3b3JkPjxrZXl3b3JkPkF1ZGl0b3J5IFRocmVzaG9sZC9waHlzaW9sb2d5PC9rZXl3b3Jk

PjxrZXl3b3JkPkNoaWxkPC9rZXl3b3JkPjxrZXl3b3JkPkNoaWxkLCBQcmVzY2hvb2w8L2tleXdv

cmQ+PGtleXdvcmQ+RGVhZi1CbGluZCBEaXNvcmRlcnMvZXBpZGVtaW9sb2d5L3BoeXNpb3BhdGhv

bG9neS8qcmVoYWJpbGl0YXRpb248L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxr

ZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbmZhbnQ8L2tleXdvcmQ+PGtleXdvcmQ+

TWFjdWxhciBEZWdlbmVyYXRpb24vZXBpZGVtaW9sb2d5L3BoeXNpb3BhdGhvbG9neS9yZWhhYmls

aXRhdGlvbjwva2V5d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3JkPk1pZGRsZSBB

Z2VkPC9rZXl3b3JkPjxrZXl3b3JkPlByZXNieWN1c2lzL2VwaWRlbWlvbG9neS9waHlzaW9wYXRo

b2xvZ3kvcmVoYWJpbGl0YXRpb248L2tleXdvcmQ+PGtleXdvcmQ+UHJldmFsZW5jZTwva2V5d29y

ZD48a2V5d29yZD5RdWViZWMvZXBpZGVtaW9sb2d5PC9rZXl3b3JkPjxrZXl3b3JkPlNleCBEaXN0

cmlidXRpb248L2tleXdvcmQ+PGtleXdvcmQ+VXNoZXIgU3luZHJvbWVzL2VwaWRlbWlvbG9neS9w

aHlzaW9wYXRob2xvZ3kvcmVoYWJpbGl0YXRpb248L2tleXdvcmQ+PGtleXdvcmQ+VmlzdWFsIEFj

dWl0eS9waHlzaW9sb2d5PC9rZXl3b3JkPjxrZXl3b3JkPlZpc3VhbCBGaWVsZHMvcGh5c2lvbG9n

eTwva2V5d29yZD48a2V5d29yZD5Zb3VuZyBBZHVsdDwva2V5d29yZD48L2tleXdvcmRzPjxkYXRl

cz48eWVhcj4yMDEyPC95ZWFyPjxwdWItZGF0ZXM+PGRhdGU+TWF5PC9kYXRlPjwvcHViLWRhdGVz

PjwvZGF0ZXM+PGlzYm4+MDI3NS01NDA4PC9pc2JuPjxhY2Nlc3Npb24tbnVtPjIyMzQ4NjUxPC9h

Y2Nlc3Npb24tbnVtPjx1cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+MTAuMTEx

MS9qLjE0NzUtMTMxMy4yMDEyLjAwODk3Lng8L2VsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjxyZW1v

dGUtZGF0YWJhc2UtcHJvdmlkZXI+TkxNPC9yZW1vdGUtZGF0YWJhc2UtcHJvdmlkZXI+PGxhbmd1

YWdlPmVuZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT4A

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XaXR0aWNoPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48

UmVjTnVtPjI0PC9SZWNOdW0+PERpc3BsYXlUZXh0PlsyNV08L0Rpc3BsYXlUZXh0PjxyZWNvcmQ+

PHJlYy1udW1iZXI+MjQ8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRi

LWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUy

Nzg0MTk1NyI+MjQ8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBB

cnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPldpdHRp

Y2gsIFcuPC9hdXRob3I+PGF1dGhvcj5XYXRhbmFiZSwgRC4gSC48L2F1dGhvcj48YXV0aG9yPkdh

Z25lLCBKLiBQLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0aC1hZGRyZXNz

PkNlbnRyZSBkZSByZWNoZXJjaGUgaW5zdGl0dXQgdW5pdmVyc2l0YWlyZSBkZSBnZXJpYXRyaWUg

ZGUgTW9udHJlYWwsIE1vbnRyZWFsIE1BQi1NYWNrYXkgUmVoYWJpbGl0YXRpb24gQ2VudHJlLCBN

b250cmVhbCwgQ2FuYWRhLiB3d2l0dGljaEBzc3NzLmdvdXYucWMuY2E8L2F1dGgtYWRkcmVzcz48

dGl0bGVzPjx0aXRsZT5TZW5zb3J5IGFuZCBkZW1vZ3JhcGhpYyBjaGFyYWN0ZXJpc3RpY3Mgb2Yg

ZGVhZmJsaW5kbmVzcyByZWhhYmlsaXRhdGlvbiBjbGllbnRzIGluIE1vbnRyZWFsLCBDYW5hZGE8

L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+T3BodGhhbG1pYyBQaHlzaW9sIE9wdDwvc2Vjb25kYXJ5

LXRpdGxlPjxhbHQtdGl0bGU+T3BodGhhbG1pYyAmYW1wOyBwaHlzaW9sb2dpY2FsIG9wdGljcyA6

IHRoZSBqb3VybmFsIG9mIHRoZSBCcml0aXNoIENvbGxlZ2Ugb2YgT3BodGhhbG1pYyBPcHRpY2lh

bnMgKE9wdG9tZXRyaXN0cyk8L2FsdC10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10

aXRsZT5PcGh0aGFsbWljIFBoeXNpb2wgT3B0PC9mdWxsLXRpdGxlPjxhYmJyLTE+T3BodGhhbG1p

YyAmYW1wOyBwaHlzaW9sb2dpY2FsIG9wdGljcyA6IHRoZSBqb3VybmFsIG9mIHRoZSBCcml0aXNo

IENvbGxlZ2Ugb2YgT3BodGhhbG1pYyBPcHRpY2lhbnMgKE9wdG9tZXRyaXN0cyk8L2FiYnItMT48

L3BlcmlvZGljYWw+PGFsdC1wZXJpb2RpY2FsPjxmdWxsLXRpdGxlPk9waHRoYWxtaWMgUGh5c2lv

bCBPcHQ8L2Z1bGwtdGl0bGU+PGFiYnItMT5PcGh0aGFsbWljICZhbXA7IHBoeXNpb2xvZ2ljYWwg

b3B0aWNzIDogdGhlIGpvdXJuYWwgb2YgdGhlIEJyaXRpc2ggQ29sbGVnZSBvZiBPcGh0aGFsbWlj

IE9wdGljaWFucyAoT3B0b21ldHJpc3RzKTwvYWJici0xPjwvYWx0LXBlcmlvZGljYWw+PHBhZ2Vz

PjI0Mi01MTwvcGFnZXM+PHZvbHVtZT4zMjwvdm9sdW1lPjxudW1iZXI+MzwvbnVtYmVyPjxlZGl0

aW9uPjIwMTIvMDIvMjI8L2VkaXRpb24+PGtleXdvcmRzPjxrZXl3b3JkPkFkb2xlc2NlbnQ8L2tl

eXdvcmQ+PGtleXdvcmQ+QWR1bHQ8L2tleXdvcmQ+PGtleXdvcmQ+QWdlIERpc3RyaWJ1dGlvbjwv

a2V5d29yZD48a2V5d29yZD5BZ2VkPC9rZXl3b3JkPjxrZXl3b3JkPkFnZWQsIDgwIGFuZCBvdmVy

PC9rZXl3b3JkPjxrZXl3b3JkPkF1ZGl0b3J5IFRocmVzaG9sZC9waHlzaW9sb2d5PC9rZXl3b3Jk

PjxrZXl3b3JkPkNoaWxkPC9rZXl3b3JkPjxrZXl3b3JkPkNoaWxkLCBQcmVzY2hvb2w8L2tleXdv

cmQ+PGtleXdvcmQ+RGVhZi1CbGluZCBEaXNvcmRlcnMvZXBpZGVtaW9sb2d5L3BoeXNpb3BhdGhv

bG9neS8qcmVoYWJpbGl0YXRpb248L2tleXdvcmQ+PGtleXdvcmQ+RmVtYWxlPC9rZXl3b3JkPjxr

ZXl3b3JkPkh1bWFuczwva2V5d29yZD48a2V5d29yZD5JbmZhbnQ8L2tleXdvcmQ+PGtleXdvcmQ+

TWFjdWxhciBEZWdlbmVyYXRpb24vZXBpZGVtaW9sb2d5L3BoeXNpb3BhdGhvbG9neS9yZWhhYmls

aXRhdGlvbjwva2V5d29yZD48a2V5d29yZD5NYWxlPC9rZXl3b3JkPjxrZXl3b3JkPk1pZGRsZSBB

Z2VkPC9rZXl3b3JkPjxrZXl3b3JkPlByZXNieWN1c2lzL2VwaWRlbWlvbG9neS9waHlzaW9wYXRo

b2xvZ3kvcmVoYWJpbGl0YXRpb248L2tleXdvcmQ+PGtleXdvcmQ+UHJldmFsZW5jZTwva2V5d29y

ZD48a2V5d29yZD5RdWViZWMvZXBpZGVtaW9sb2d5PC9rZXl3b3JkPjxrZXl3b3JkPlNleCBEaXN0

cmlidXRpb248L2tleXdvcmQ+PGtleXdvcmQ+VXNoZXIgU3luZHJvbWVzL2VwaWRlbWlvbG9neS9w

aHlzaW9wYXRob2xvZ3kvcmVoYWJpbGl0YXRpb248L2tleXdvcmQ+PGtleXdvcmQ+VmlzdWFsIEFj

dWl0eS9waHlzaW9sb2d5PC9rZXl3b3JkPjxrZXl3b3JkPlZpc3VhbCBGaWVsZHMvcGh5c2lvbG9n

eTwva2V5d29yZD48a2V5d29yZD5Zb3VuZyBBZHVsdDwva2V5d29yZD48L2tleXdvcmRzPjxkYXRl

cz48eWVhcj4yMDEyPC95ZWFyPjxwdWItZGF0ZXM+PGRhdGU+TWF5PC9kYXRlPjwvcHViLWRhdGVz

PjwvZGF0ZXM+PGlzYm4+MDI3NS01NDA4PC9pc2JuPjxhY2Nlc3Npb24tbnVtPjIyMzQ4NjUxPC9h

Y2Nlc3Npb24tbnVtPjx1cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+MTAuMTEx

MS9qLjE0NzUtMTMxMy4yMDEyLjAwODk3Lng8L2VsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjxyZW1v

dGUtZGF0YWJhc2UtcHJvdmlkZXI+TkxNPC9yZW1vdGUtZGF0YWJhc2UtcHJvdmlkZXI+PGxhbmd1

YWdlPmVuZzwvbGFuZ3VhZ2U+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT4A

ADDIN EN.CITE.DATA [25].Figure 13. Proportion of persons with deafblindness reporting other functional limitationsThe literature review also found evidence that persons with deafblindness may experience poorer levels of health and barriers to accessing health services. These studies are, however, mostly restricted to high-income settings. For example, persons with deafblindness reported poorer self-rated health in the United States and Japan PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYXJhZGE8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS

ZWNOdW0+NTwvUmVjTnVtPjxEaXNwbGF5VGV4dD5bMTQsIDI3LCAyOF08L0Rpc3BsYXlUZXh0Pjxy

ZWNvcmQ+PHJlYy1udW1iZXI+NTwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJF

TiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1w

PSIxNTI3ODQxOTU3Ij41PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJu

YWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5I

YXJhZGEsIFNlaTwvYXV0aG9yPjxhdXRob3I+TmlzaGl3YWtpLCBZdWppPC9hdXRob3I+PGF1dGhv

cj5NaWNoaWthd2EsIFRha2VoaXJvPC9hdXRob3I+PGF1dGhvcj5LaWt1Y2hpLCBZdXJpa288L2F1

dGhvcj48YXV0aG9yPkl3YXNhd2EsIFNhdG9rbzwvYXV0aG9yPjxhdXRob3I+TmFrYW5vLCBNYWtp

a288L2F1dGhvcj48YXV0aG9yPklzaGlnYW1pLCBBaTwvYXV0aG9yPjxhdXRob3I+U2FpdG8sIEhp

ZGV5dWtpPC9hdXRob3I+PGF1dGhvcj5UYWtlYmF5YXNoaSwgVG9ydTwvYXV0aG9yPjwvYXV0aG9y

cz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5HZW5kZXIgZGlmZmVyZW5jZSBpbiB0aGUg

cmVsYXRpb25zaGlwcyBiZXR3ZWVuIHZpc2lvbiBhbmQgaGVhcmluZyBpbXBhaXJtZW50cyBhbmQg

bmVnYXRpdmUgd2VsbC1iZWluZzwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5QcmV2ZW50aXZlIG1l

ZGljaW5lPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+

UHJldmVudGl2ZSBtZWRpY2luZTwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjQzMy00

Mzc8L3BhZ2VzPjx2b2x1bWU+NDc8L3ZvbHVtZT48bnVtYmVyPjQ8L251bWJlcj48ZGF0ZXM+PHll

YXI+MjAwODwveWVhcj48L2RhdGVzPjxpc2JuPjAwOTEtNzQzNTwvaXNibj48dXJscz48L3VybHM+

PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+Q3Jld3M8L0F1dGhvcj48WWVhcj4yMDA0PC9Z

ZWFyPjxSZWNOdW0+MjY8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjI2PC9yZWMtbnVtYmVy

Pjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3

ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTciPjI2PC9rZXk+PC9mb3JlaWdu

LWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250

cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5DcmV3cywgSm9obiBFPC9hdXRob3I+PGF1dGhvcj5D

YW1wYmVsbCwgVmluY2VudCBBPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRs

ZXM+PHRpdGxlPlZpc2lvbiBpbXBhaXJtZW50IGFuZCBoZWFyaW5nIGxvc3MgYW1vbmcgY29tbXVu

aXR5LWR3ZWxsaW5nIG9sZGVyIEFtZXJpY2FuczogaW1wbGljYXRpb25zIGZvciBoZWFsdGggYW5k

IGZ1bmN0aW9uaW5nPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkFtZXJpY2FuIGpvdXJuYWwgb2Yg

cHVibGljIGhlYWx0aDwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxs

LXRpdGxlPkFtZXJpY2FuIEpvdXJuYWwgb2YgUHVibGljIEhlYWx0aDwvZnVsbC10aXRsZT48L3Bl

cmlvZGljYWw+PHBhZ2VzPjgyMy04Mjk8L3BhZ2VzPjx2b2x1bWU+OTQ8L3ZvbHVtZT48bnVtYmVy

PjU8L251bWJlcj48ZGF0ZXM+PHllYXI+MjAwNDwveWVhcj48L2RhdGVzPjxpc2JuPjAwOTAtMDAz

NjwvaXNibj48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+TWNEb25u

YWxsPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48UmVjTnVtPjI3PC9SZWNOdW0+PHJlY29yZD48

cmVjLW51bWJlcj4yNzwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGIt

aWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3

ODQxOTU3Ij4yNzwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFy

dGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+TWNEb25u

YWxsLCBNaWNoZWxlIEM8L2F1dGhvcj48YXV0aG9yPkNydWRkZW4sIEFkZWxlPC9hdXRob3I+PGF1

dGhvcj5MZUpldW5lLCBCSjwvYXV0aG9yPjxhdXRob3I+U3RldmVyc29uLCBBbm5lPC9hdXRob3I+

PGF1dGhvcj5PJmFwb3M7RG9ubmVsbCwgTmFuY3k8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmli

dXRvcnM+PHRpdGxlcz48dGl0bGU+TmVlZHMgYW5kIENoYWxsZW5nZXMgb2YgU2VuaW9ycyB3aXRo

IENvbWJpbmVkIEhlYXJpbmcgYW5kIFZpc2lvbiBMb3NzPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxl

PkpvdXJuYWwgb2YgVmlzdWFsIEltcGFpcm1lbnQgJmFtcDsgQmxpbmRuZXNzIChPbmxpbmUpPC9z

ZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+Sm91cm5hbCBv

ZiBWaXN1YWwgSW1wYWlybWVudCAmYW1wOyBCbGluZG5lc3MgKE9ubGluZSk8L2Z1bGwtdGl0bGU+

PC9wZXJpb2RpY2FsPjxwYWdlcz4zOTk8L3BhZ2VzPjx2b2x1bWU+MTEwPC92b2x1bWU+PG51bWJl

cj42PC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTY8L3llYXI+PC9kYXRlcz48aXNibj4xNTU5LTE0

NzY8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48L0VuZE5vdGU+

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYXJhZGE8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS

ZWNOdW0+NTwvUmVjTnVtPjxEaXNwbGF5VGV4dD5bMTQsIDI3LCAyOF08L0Rpc3BsYXlUZXh0Pjxy

ZWNvcmQ+PHJlYy1udW1iZXI+NTwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJF

TiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1w

PSIxNTI3ODQxOTU3Ij41PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJu

YWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5I

YXJhZGEsIFNlaTwvYXV0aG9yPjxhdXRob3I+TmlzaGl3YWtpLCBZdWppPC9hdXRob3I+PGF1dGhv

cj5NaWNoaWthd2EsIFRha2VoaXJvPC9hdXRob3I+PGF1dGhvcj5LaWt1Y2hpLCBZdXJpa288L2F1

dGhvcj48YXV0aG9yPkl3YXNhd2EsIFNhdG9rbzwvYXV0aG9yPjxhdXRob3I+TmFrYW5vLCBNYWtp

a288L2F1dGhvcj48YXV0aG9yPklzaGlnYW1pLCBBaTwvYXV0aG9yPjxhdXRob3I+U2FpdG8sIEhp

ZGV5dWtpPC9hdXRob3I+PGF1dGhvcj5UYWtlYmF5YXNoaSwgVG9ydTwvYXV0aG9yPjwvYXV0aG9y

cz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5HZW5kZXIgZGlmZmVyZW5jZSBpbiB0aGUg

cmVsYXRpb25zaGlwcyBiZXR3ZWVuIHZpc2lvbiBhbmQgaGVhcmluZyBpbXBhaXJtZW50cyBhbmQg

bmVnYXRpdmUgd2VsbC1iZWluZzwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5QcmV2ZW50aXZlIG1l

ZGljaW5lPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+

UHJldmVudGl2ZSBtZWRpY2luZTwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjQzMy00

Mzc8L3BhZ2VzPjx2b2x1bWU+NDc8L3ZvbHVtZT48bnVtYmVyPjQ8L251bWJlcj48ZGF0ZXM+PHll

YXI+MjAwODwveWVhcj48L2RhdGVzPjxpc2JuPjAwOTEtNzQzNTwvaXNibj48dXJscz48L3VybHM+

PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+Q3Jld3M8L0F1dGhvcj48WWVhcj4yMDA0PC9Z

ZWFyPjxSZWNOdW0+MjY8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjI2PC9yZWMtbnVtYmVy

Pjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3

ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTciPjI2PC9rZXk+PC9mb3JlaWdu

LWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250

cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5DcmV3cywgSm9obiBFPC9hdXRob3I+PGF1dGhvcj5D

YW1wYmVsbCwgVmluY2VudCBBPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRs

ZXM+PHRpdGxlPlZpc2lvbiBpbXBhaXJtZW50IGFuZCBoZWFyaW5nIGxvc3MgYW1vbmcgY29tbXVu

aXR5LWR3ZWxsaW5nIG9sZGVyIEFtZXJpY2FuczogaW1wbGljYXRpb25zIGZvciBoZWFsdGggYW5k

IGZ1bmN0aW9uaW5nPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkFtZXJpY2FuIGpvdXJuYWwgb2Yg

cHVibGljIGhlYWx0aDwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxs

LXRpdGxlPkFtZXJpY2FuIEpvdXJuYWwgb2YgUHVibGljIEhlYWx0aDwvZnVsbC10aXRsZT48L3Bl

cmlvZGljYWw+PHBhZ2VzPjgyMy04Mjk8L3BhZ2VzPjx2b2x1bWU+OTQ8L3ZvbHVtZT48bnVtYmVy

PjU8L251bWJlcj48ZGF0ZXM+PHllYXI+MjAwNDwveWVhcj48L2RhdGVzPjxpc2JuPjAwOTAtMDAz

NjwvaXNibj48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+TWNEb25u

YWxsPC9BdXRob3I+PFllYXI+MjAxNjwvWWVhcj48UmVjTnVtPjI3PC9SZWNOdW0+PHJlY29yZD48

cmVjLW51bWJlcj4yNzwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGIt

aWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3

ODQxOTU3Ij4yNzwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFy

dGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+TWNEb25u

YWxsLCBNaWNoZWxlIEM8L2F1dGhvcj48YXV0aG9yPkNydWRkZW4sIEFkZWxlPC9hdXRob3I+PGF1

dGhvcj5MZUpldW5lLCBCSjwvYXV0aG9yPjxhdXRob3I+U3RldmVyc29uLCBBbm5lPC9hdXRob3I+

PGF1dGhvcj5PJmFwb3M7RG9ubmVsbCwgTmFuY3k8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmli

dXRvcnM+PHRpdGxlcz48dGl0bGU+TmVlZHMgYW5kIENoYWxsZW5nZXMgb2YgU2VuaW9ycyB3aXRo

IENvbWJpbmVkIEhlYXJpbmcgYW5kIFZpc2lvbiBMb3NzPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxl

PkpvdXJuYWwgb2YgVmlzdWFsIEltcGFpcm1lbnQgJmFtcDsgQmxpbmRuZXNzIChPbmxpbmUpPC9z

ZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+Sm91cm5hbCBv

ZiBWaXN1YWwgSW1wYWlybWVudCAmYW1wOyBCbGluZG5lc3MgKE9ubGluZSk8L2Z1bGwtdGl0bGU+

PC9wZXJpb2RpY2FsPjxwYWdlcz4zOTk8L3BhZ2VzPjx2b2x1bWU+MTEwPC92b2x1bWU+PG51bWJl

cj42PC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTY8L3llYXI+PC9kYXRlcz48aXNibj4xNTU5LTE0

NzY8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48L0VuZE5vdGU+

ADDIN EN.CITE.DATA [14, 27, 28], as well as increased mortality rates PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYWZvcmdlPC9BdXRob3I+PFllYXI+MTk5MjwvWWVhcj48

UmVjTnVtPjI4PC9SZWNOdW0+PERpc3BsYXlUZXh0PlsyOS0zMV08L0Rpc3BsYXlUZXh0PjxyZWNv

cmQ+PHJlYy1udW1iZXI+Mjg8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4i

IGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0i

MTUyNzg0MTk1NyI+Mjg8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5h

bCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkxh

Zm9yZ2UsIFJvYmVydCBHPC9hdXRob3I+PGF1dGhvcj5TcGVjdG9yLCBXaWxsaWFtIEQ8L2F1dGhv

cj48YXV0aG9yPlN0ZXJuYmVyZywgSm9zZWY8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRv

cnM+PHRpdGxlcz48dGl0bGU+VGhlIHJlbGF0aW9uc2hpcCBvZiB2aXNpb24gYW5kIGhlYXJpbmcg

aW1wYWlybWVudCB0byBvbmUteWVhciBtb3J0YWxpdHkgYW5kIGZ1bmN0aW9uYWwgZGVjbGluZTwv

dGl0bGU+PHNlY29uZGFyeS10aXRsZT5Kb3VybmFsIG9mIEFnaW5nIGFuZCBIZWFsdGg8L3NlY29u

ZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5Kb3VybmFsIG9mIEFn

aW5nIGFuZCBIZWFsdGg8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4xMjYtMTQ4PC9w

YWdlcz48dm9sdW1lPjQ8L3ZvbHVtZT48bnVtYmVyPjE8L251bWJlcj48ZGF0ZXM+PHllYXI+MTk5

MjwveWVhcj48L2RhdGVzPjxpc2JuPjA4OTgtMjY0MzwvaXNibj48dXJscz48L3VybHM+PC9yZWNv

cmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+TGFtPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48UmVj

TnVtPjI5PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4yOTwvcmVjLW51bWJlcj48Zm9yZWln

bi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4

ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3ODQxOTU3Ij4yOTwva2V5PjwvZm9yZWlnbi1rZXlzPjxy

ZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3Jz

PjxhdXRob3JzPjxhdXRob3I+TGFtLCBCeXJvbiBMPC9hdXRob3I+PGF1dGhvcj5MZWUsIERhdmlk

IEo8L2F1dGhvcj48YXV0aG9yPkfDs21lei1NYXLDrW4sIE9ybGFuZG88L2F1dGhvcj48YXV0aG9y

PlpoZW5nLCBEIERpYW5lPC9hdXRob3I+PGF1dGhvcj5DYWJhbiwgQWxiZXJ0byBKPC9hdXRob3I+

PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkNvbmN1cnJlbnQgdmlzdWFs

IGFuZCBoZWFyaW5nIGltcGFpcm1lbnQgYW5kIHJpc2sgb2YgbW9ydGFsaXR5OiB0aGUgTmF0aW9u

YWwgSGVhbHRoIEludGVydmlldyBTdXJ2ZXk8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+QXJjaGl2

ZXMgb2Ygb3BodGhhbG1vbG9neTwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2Fs

PjxmdWxsLXRpdGxlPkFyY2hpdmVzIG9mIE9waHRoYWxtb2xvZ3k8L2Z1bGwtdGl0bGU+PC9wZXJp

b2RpY2FsPjxwYWdlcz45NS0xMDE8L3BhZ2VzPjx2b2x1bWU+MTI0PC92b2x1bWU+PG51bWJlcj4x

PC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMDY8L3llYXI+PC9kYXRlcz48aXNibj4wMDAzLTk5NTA8

L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPkxpbGphczwv

QXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJlY051bT4zMDwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1u

dW1iZXI+MzA8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6

dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1

NyI+MzA8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iR2VuZXJpYyI+MTM8L3Jl

Zi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5MaWxqYXMsIEFFTTwvYXV0aG9y

PjxhdXRob3I+V2FubmFtZXRoZWUsIFNHPC9hdXRob3I+PGF1dGhvcj5XaGluY3VwLCBQSDwvYXV0

aG9yPjxhdXRob3I+UGFwYWNvc3RhLCBPPC9hdXRob3I+PGF1dGhvcj5XYWx0ZXJzLCBLPC9hdXRo

b3I+PGF1dGhvcj5JbGlmZmUsIFM8L2F1dGhvcj48YXV0aG9yPkxlbm5vbiwgTFQ8L2F1dGhvcj48

YXV0aG9yPkNhcnZhbGhvLCBMQTwvYXV0aG9yPjxhdXRob3I+UmFtc2F5LCBTRTwvYXV0aG9yPjwv

YXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5PUDA3IFNlbnNvcnkgaW1wYWly

bWVudHMgYW5kIG1vcnRhbGl0eSBpbiBvbGRlciBicml0aXNoIGNvbW11bml0eS1kd2VsbGluZyBt

ZW46IGEgMTAteWVhciBmb2xsb3ctdXAgc3R1ZHk8L3RpdGxlPjwvdGl0bGVzPjxkYXRlcz48eWVh

cj4yMDE1PC95ZWFyPjwvZGF0ZXM+PHB1Ymxpc2hlcj5CTUogUHVibGlzaGluZyBHcm91cCBMdGQ8

L3B1Ymxpc2hlcj48aXNibj4wMTQzLTAwNVg8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwv

Q2l0ZT48L0VuZE5vdGU+

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MYWZvcmdlPC9BdXRob3I+PFllYXI+MTk5MjwvWWVhcj48

UmVjTnVtPjI4PC9SZWNOdW0+PERpc3BsYXlUZXh0PlsyOS0zMV08L0Rpc3BsYXlUZXh0PjxyZWNv

cmQ+PHJlYy1udW1iZXI+Mjg8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4i

IGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0i

MTUyNzg0MTk1NyI+Mjg8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5h

bCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkxh

Zm9yZ2UsIFJvYmVydCBHPC9hdXRob3I+PGF1dGhvcj5TcGVjdG9yLCBXaWxsaWFtIEQ8L2F1dGhv

cj48YXV0aG9yPlN0ZXJuYmVyZywgSm9zZWY8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRv

cnM+PHRpdGxlcz48dGl0bGU+VGhlIHJlbGF0aW9uc2hpcCBvZiB2aXNpb24gYW5kIGhlYXJpbmcg

aW1wYWlybWVudCB0byBvbmUteWVhciBtb3J0YWxpdHkgYW5kIGZ1bmN0aW9uYWwgZGVjbGluZTwv

dGl0bGU+PHNlY29uZGFyeS10aXRsZT5Kb3VybmFsIG9mIEFnaW5nIGFuZCBIZWFsdGg8L3NlY29u

ZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5Kb3VybmFsIG9mIEFn

aW5nIGFuZCBIZWFsdGg8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4xMjYtMTQ4PC9w

YWdlcz48dm9sdW1lPjQ8L3ZvbHVtZT48bnVtYmVyPjE8L251bWJlcj48ZGF0ZXM+PHllYXI+MTk5

MjwveWVhcj48L2RhdGVzPjxpc2JuPjA4OTgtMjY0MzwvaXNibj48dXJscz48L3VybHM+PC9yZWNv

cmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+TGFtPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48UmVj

TnVtPjI5PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4yOTwvcmVjLW51bWJlcj48Zm9yZWln

bi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4

ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3ODQxOTU3Ij4yOTwva2V5PjwvZm9yZWlnbi1rZXlzPjxy

ZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3Jz

PjxhdXRob3JzPjxhdXRob3I+TGFtLCBCeXJvbiBMPC9hdXRob3I+PGF1dGhvcj5MZWUsIERhdmlk

IEo8L2F1dGhvcj48YXV0aG9yPkfDs21lei1NYXLDrW4sIE9ybGFuZG88L2F1dGhvcj48YXV0aG9y

PlpoZW5nLCBEIERpYW5lPC9hdXRob3I+PGF1dGhvcj5DYWJhbiwgQWxiZXJ0byBKPC9hdXRob3I+

PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkNvbmN1cnJlbnQgdmlzdWFs

IGFuZCBoZWFyaW5nIGltcGFpcm1lbnQgYW5kIHJpc2sgb2YgbW9ydGFsaXR5OiB0aGUgTmF0aW9u

YWwgSGVhbHRoIEludGVydmlldyBTdXJ2ZXk8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+QXJjaGl2

ZXMgb2Ygb3BodGhhbG1vbG9neTwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2Fs

PjxmdWxsLXRpdGxlPkFyY2hpdmVzIG9mIE9waHRoYWxtb2xvZ3k8L2Z1bGwtdGl0bGU+PC9wZXJp

b2RpY2FsPjxwYWdlcz45NS0xMDE8L3BhZ2VzPjx2b2x1bWU+MTI0PC92b2x1bWU+PG51bWJlcj4x

PC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMDY8L3llYXI+PC9kYXRlcz48aXNibj4wMDAzLTk5NTA8

L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPkxpbGphczwv

QXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+PFJlY051bT4zMDwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1u

dW1iZXI+MzA8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6

dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1

NyI+MzA8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iR2VuZXJpYyI+MTM8L3Jl

Zi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5MaWxqYXMsIEFFTTwvYXV0aG9y

PjxhdXRob3I+V2FubmFtZXRoZWUsIFNHPC9hdXRob3I+PGF1dGhvcj5XaGluY3VwLCBQSDwvYXV0

aG9yPjxhdXRob3I+UGFwYWNvc3RhLCBPPC9hdXRob3I+PGF1dGhvcj5XYWx0ZXJzLCBLPC9hdXRo

b3I+PGF1dGhvcj5JbGlmZmUsIFM8L2F1dGhvcj48YXV0aG9yPkxlbm5vbiwgTFQ8L2F1dGhvcj48

YXV0aG9yPkNhcnZhbGhvLCBMQTwvYXV0aG9yPjxhdXRob3I+UmFtc2F5LCBTRTwvYXV0aG9yPjwv

YXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5PUDA3IFNlbnNvcnkgaW1wYWly

bWVudHMgYW5kIG1vcnRhbGl0eSBpbiBvbGRlciBicml0aXNoIGNvbW11bml0eS1kd2VsbGluZyBt

ZW46IGEgMTAteWVhciBmb2xsb3ctdXAgc3R1ZHk8L3RpdGxlPjwvdGl0bGVzPjxkYXRlcz48eWVh

cj4yMDE1PC95ZWFyPjwvZGF0ZXM+PHB1Ymxpc2hlcj5CTUogUHVibGlzaGluZyBHcm91cCBMdGQ8

L3B1Ymxpc2hlcj48aXNibj4wMTQzLTAwNVg8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwv

Q2l0ZT48L0VuZE5vdGU+

ADDIN EN.CITE.DATA [29-31]. Common challenges to accessing both general health and rehabilitation services included: a lack of accommodations in health facilities, particularly in terms of accessible information and alternative forms of communication; costs of accessing care, as insurance often does not always cover all expenses; concentration of services in cities, with little available in rural areas; and a lack of knowledge of and training on deafblindness among health professionals ADDIN EN.CITE <EndNote><Cite><Author>Guthrie</Author><Year>2016</Year><RecNum>31</RecNum><DisplayText>[12, 32]</DisplayText><record><rec-number>31</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">31</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Guthrie, Dawn M</author><author>Declercq, Anja</author><author>Finne-Soveri, Harriet</author><author>Fries, Brant E</author><author>Hirdes, John P</author></authors></contributors><titles><title>The health and well-being of older adults with Dual Sensory Impairment (DSI) in four countries</title><secondary-title>PloS one</secondary-title></titles><periodical><full-title>PloS one</full-title></periodical><pages>e0155073</pages><volume>11</volume><number>5</number><dates><year>2016</year></dates><isbn>1932-6203</isbn><urls></urls></record></Cite><Cite><Author>Saunders</Author><Year>2007</Year><RecNum>32</RecNum><record><rec-number>32</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">32</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Saunders, Gabrielle H</author><author>Echt, Katharina V</author></authors></contributors><titles><title>An overview of dual sensory impairment in older adults: perspectives for rehabilitation</title><secondary-title>Trends in amplification</secondary-title></titles><periodical><full-title>Trends in amplification</full-title></periodical><pages>243-258</pages><volume>11</volume><number>4</number><dates><year>2007</year></dates><isbn>1084-7138</isbn><urls></urls></record></Cite></EndNote>[12, 32].There is also a growing body of research demonstrating that persons with deafblindness are more likely to experience depression and other mental health conditions compared to both people without sensory impairments or with visual or hearing impairment alone PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Cb2Rzd29ydGg8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy

PjxSZWNOdW0+MzM8L1JlY051bT48RGlzcGxheVRleHQ+WzEzLCAzMy0zOV08L0Rpc3BsYXlUZXh0

PjxyZWNvcmQ+PHJlYy1udW1iZXI+MzM8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFw

cD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVz

dGFtcD0iMTUyNzg0MTk1NyI+MzM8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0i

Sm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0

aG9yPkJvZHN3b3J0aCwgU2FyYWggTTwvYXV0aG9yPjxhdXRob3I+Q2xhcmUsIElzYWJlbCBDSDwv

YXV0aG9yPjxhdXRob3I+U2ltYmxldHQsIFNhcmEgSzwvYXV0aG9yPjxhdXRob3I+RGVhZmJsaW5k

IFVLPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkRlYWZi

bGluZG5lc3MgYW5kIG1lbnRhbCBoZWFsdGg6IFBzeWNob2xvZ2ljYWwgZGlzdHJlc3MgYW5kIHVu

bWV0IG5lZWQgYW1vbmcgYWR1bHRzIHdpdGggZHVhbCBzZW5zb3J5IGltcGFpcm1lbnQ8L3RpdGxl

PjxzZWNvbmRhcnktdGl0bGU+QnJpdGlzaCBKb3VybmFsIG9mIFZpc3VhbCBJbXBhaXJtZW50PC9z

ZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+QnJpdGlzaCBK

b3VybmFsIG9mIFZpc3VhbCBJbXBhaXJtZW50PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFn

ZXM+Ni0yNjwvcGFnZXM+PHZvbHVtZT4yOTwvdm9sdW1lPjxudW1iZXI+MTwvbnVtYmVyPjxkYXRl

cz48eWVhcj4yMDExPC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDI2NC02MTk2PC9pc2JuPjx1cmxzPjwv

dXJscz48L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5DaGlhPC9BdXRob3I+PFllYXI+MjAw

NjwvWWVhcj48UmVjTnVtPjQ8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjQ8L3JlYy1udW1i

ZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2

dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+NDwva2V5PjwvZm9yZWln

bi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29u

dHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Q2hpYSwgRWUtTXVubjwvYXV0aG9yPjxhdXRob3I+

TWl0Y2hlbGwsIFBhdWw8L2F1dGhvcj48YXV0aG9yPlJvY2h0Y2hpbmEsIEVsZW5hPC9hdXRob3I+

PGF1dGhvcj5Gb3JhbiwgU3VyaXlhPC9hdXRob3I+PGF1dGhvcj5Hb2xkaW5nLCBNYXJ5YW5uZTwv

YXV0aG9yPjxhdXRob3I+V2FuZywgSmllIEppbjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1

dG9ycz48dGl0bGVzPjx0aXRsZT5Bc3NvY2lhdGlvbiBiZXR3ZWVuIHZpc2lvbiBhbmQgaGVhcmlu

ZyBpbXBhaXJtZW50cyBhbmQgdGhlaXIgY29tYmluZWQgZWZmZWN0cyBvbiBxdWFsaXR5IG9mIGxp

ZmU8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+QXJjaGl2ZXMgb2YgT3BodGhhbG1vbG9neTwvc2Vj

b25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkFyY2hpdmVzIG9m

IE9waHRoYWxtb2xvZ3k8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4xNDY1LTE0NzA8

L3BhZ2VzPjx2b2x1bWU+MTI0PC92b2x1bWU+PG51bWJlcj4xMDwvbnVtYmVyPjxkYXRlcz48eWVh

cj4yMDA2PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDAwMy05OTUwPC9pc2JuPjx1cmxzPjwvdXJscz48

L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5DaG91PC9BdXRob3I+PFllYXI+MjAwNDwvWWVh

cj48UmVjTnVtPjM0PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4zNDwvcmVjLW51bWJlcj48

Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2Rz

N2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3ODQxOTU3Ij4zNDwva2V5PjwvZm9yZWlnbi1r

ZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJp

YnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Q2hvdSwgS2Vl4oCQTGVlPC9hdXRob3I+PGF1dGhvcj5D

aGksIElyaXM8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PHRpdGxlcz48dGl0bGU+

Q29tYmluZWQgZWZmZWN0IG9mIHZpc2lvbiBhbmQgaGVhcmluZyBpbXBhaXJtZW50IG9uIGRlcHJl

c3Npb24gaW4gZWxkZXJseSBDaGluZXNlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkludGVybmF0

aW9uYWwgam91cm5hbCBvZiBnZXJpYXRyaWMgcHN5Y2hpYXRyeTwvc2Vjb25kYXJ5LXRpdGxlPjwv

dGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkludGVybmF0aW9uYWwgam91cm5hbCBvZiBn

ZXJpYXRyaWMgcHN5Y2hpYXRyeTwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjgyNS04

MzI8L3BhZ2VzPjx2b2x1bWU+MTk8L3ZvbHVtZT48bnVtYmVyPjk8L251bWJlcj48ZGF0ZXM+PHll

YXI+MjAwNDwveWVhcj48L2RhdGVzPjxpc2JuPjEwOTktMTE2NjwvaXNibj48dXJscz48L3VybHM+

PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+Q2FwZWxsYeKAkE1jRG9ubmFsbDwvQXV0aG9y

PjxZZWFyPjIwMDU8L1llYXI+PFJlY051bT4zNTwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+

MzU8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4

OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+MzU8

L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwv

cmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkNhcGVsbGHigJBNY0Rvbm5h

bGwsIE1pY2hlbGUgRTwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0

aXRsZT5UaGUgZWZmZWN0cyBvZiBzaW5nbGUgYW5kIGR1YWwgc2Vuc29yeSBsb3NzIG9uIHN5bXB0

b21zIG9mIGRlcHJlc3Npb24gaW4gdGhlIGVsZGVybHk8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+

SW50ZXJuYXRpb25hbCBqb3VybmFsIG9mIGdlcmlhdHJpYyBwc3ljaGlhdHJ5PC9zZWNvbmRhcnkt

dGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+SW50ZXJuYXRpb25hbCBqb3Vy

bmFsIG9mIGdlcmlhdHJpYyBwc3ljaGlhdHJ5PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFn

ZXM+ODU1LTg2MTwvcGFnZXM+PHZvbHVtZT4yMDwvdm9sdW1lPjxudW1iZXI+OTwvbnVtYmVyPjxk

YXRlcz48eWVhcj4yMDA1PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MTA5OS0xMTY2PC9pc2JuPjx1cmxz

PjwvdXJscz48L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5MdXBzYWtrbzwvQXV0aG9yPjxZ

ZWFyPjIwMDI8L1llYXI+PFJlY051bT4zNjwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+MzY8

L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0

ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+MzY8L2tl

eT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVm

LXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkx1cHNha2tvLCBUYWluYTwvYXV0

aG9yPjxhdXRob3I+TcOkbnR5asOkcnZpLCBNYWlqYTwvYXV0aG9yPjxhdXRob3I+S2F1dGlhaW5l

biwgSGFubnU8L2F1dGhvcj48YXV0aG9yPlN1bGthdmEsIFJhaW1vPC9hdXRob3I+PC9hdXRob3Jz

PjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkNvbWJpbmVkIGhlYXJpbmcgYW5kIHZpc3Vh

bCBpbXBhaXJtZW50IGFuZCBkZXByZXNzaW9uIGluIGEgcG9wdWxhdGlvbiBhZ2VkIDc1IHllYXJz

IGFuZCBvbGRlcjwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5JbnRlcm5hdGlvbmFsIGpvdXJuYWwg

b2YgZ2VyaWF0cmljIHBzeWNoaWF0cnk8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9k

aWNhbD48ZnVsbC10aXRsZT5JbnRlcm5hdGlvbmFsIGpvdXJuYWwgb2YgZ2VyaWF0cmljIHBzeWNo

aWF0cnk8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz44MDgtODEzPC9wYWdlcz48dm9s

dW1lPjE3PC92b2x1bWU+PG51bWJlcj45PC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMDI8L3llYXI+

PC9kYXRlcz48aXNibj4xMDk5LTExNjY8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0

ZT48Q2l0ZT48QXV0aG9yPkhlaW5lPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48UmVjTnVtPjM3

PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4zNzwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlz

PjxrZXkgYXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZz

eCIgdGltZXN0YW1wPSIxNTI3ODQxOTU3Ij4zNzwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlw

ZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRo

b3JzPjxhdXRob3I+SGVpbmUsIENoeXJpc3NlPC9hdXRob3I+PGF1dGhvcj5Ccm93bmluZywgQ29s

ZXR0ZSBKPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPk1l

bnRhbCBoZWFsdGggYW5kIGR1YWwgc2Vuc29yeSBsb3NzIGluIG9sZGVyIGFkdWx0czogYSBzeXN0

ZW1hdGljIHJldmlldzwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5Gcm9udGllcnMgaW4gYWdpbmcg

bmV1cm9zY2llbmNlPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwt

dGl0bGU+RnJvbnRpZXJzIGluIGFnaW5nIG5ldXJvc2NpZW5jZTwvZnVsbC10aXRsZT48L3Blcmlv

ZGljYWw+PHBhZ2VzPjgzPC9wYWdlcz48dm9sdW1lPjY8L3ZvbHVtZT48ZGF0ZXM+PHllYXI+MjAx

NDwveWVhcj48L2RhdGVzPjxpc2JuPjE2NjMtNDM2NTwvaXNibj48dXJscz48L3VybHM+PC9yZWNv

cmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+Q29zaDwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl

Y051bT4zODwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+Mzg8L3JlYy1udW1iZXI+PGZvcmVp

Z24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4

eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+Mzg8L2tleT48L2ZvcmVpZ24ta2V5cz48

cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9y

cz48YXV0aG9ycz48YXV0aG9yPkNvc2gsIFM8L2F1dGhvcj48YXV0aG9yPkhhbm5vLCBUPC9hdXRo

b3I+PGF1dGhvcj5IZWxtZXIsIEM8L2F1dGhvcj48YXV0aG9yPkJlcnRlbHNlbiwgRzwvYXV0aG9y

PjxhdXRob3I+RGVsY291cnQsIEM8L2F1dGhvcj48YXV0aG9yPlNjaGlybWVyLCBIPC9hdXRob3I+

PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPlRoZSBhc3NvY2lhdGlvbiBh

bW9uZ3N0IHZpc3VhbCwgaGVhcmluZywgYW5kIGR1YWwgc2Vuc29yeSBsb3NzIHdpdGggZGVwcmVz

c2lvbiBhbmQgYW54aWV0eSBvdmVyIDYgeWVhcnM6IFRoZSBUcm9tc8O4IFN0dWR5PC90aXRsZT48

c2Vjb25kYXJ5LXRpdGxlPkludGVybmF0aW9uYWwgSm91cm5hbCBvZiBHZXJpYXRyaWMgUHN5Y2hp

YXRyeTwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPklu

dGVybmF0aW9uYWwgam91cm5hbCBvZiBnZXJpYXRyaWMgcHN5Y2hpYXRyeTwvZnVsbC10aXRsZT48

L3BlcmlvZGljYWw+PGRhdGVzPjx5ZWFyPjIwMTc8L3llYXI+PC9kYXRlcz48aXNibj4xMDk5LTEx

NjY8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPkRhdmlk

c29uPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48UmVjTnVtPjM5PC9SZWNOdW0+PHJlY29yZD48

cmVjLW51bWJlcj4zOTwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGIt

aWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3

ODQxOTU3Ij4zOTwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFy

dGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+RGF2aWRz

b24sIEphY29iIEdTPC9hdXRob3I+PGF1dGhvcj5HdXRocmllLCBEYXduIE08L2F1dGhvcj48L2F1

dGhvcnM+PC9jb250cmlidXRvcnM+PHRpdGxlcz48dGl0bGU+T2xkZXIgYWR1bHRzIHdpdGggYSBj

b21iaW5hdGlvbiBvZiB2aXNpb24gYW5kIGhlYXJpbmcgaW1wYWlybWVudCBleHBlcmllbmNlIGhp

Z2hlciByYXRlcyBvZiBjb2duaXRpdmUgaW1wYWlybWVudCwgZnVuY3Rpb25hbCBkZXBlbmRlbmNl

LCBhbmQgd29yc2Ugb3V0Y29tZXMgYWNyb3NzIGEgc2V0IG9mIHF1YWxpdHkgaW5kaWNhdG9yczwv

dGl0bGU+PHNlY29uZGFyeS10aXRsZT5Kb3VybmFsIG9mIGFnaW5nIGFuZCBoZWFsdGg8L3NlY29u

ZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5Kb3VybmFsIG9mIEFn

aW5nIGFuZCBIZWFsdGg8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4wODk4MjY0MzE3

NzIzNDA3PC9wYWdlcz48ZGF0ZXM+PHllYXI+MjAxNzwveWVhcj48L2RhdGVzPjxpc2JuPjA4OTgt

MjY0MzwvaXNibj48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT4A

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Cb2Rzd29ydGg8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFy

PjxSZWNOdW0+MzM8L1JlY051bT48RGlzcGxheVRleHQ+WzEzLCAzMy0zOV08L0Rpc3BsYXlUZXh0

PjxyZWNvcmQ+PHJlYy1udW1iZXI+MzM8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFw

cD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVz

dGFtcD0iMTUyNzg0MTk1NyI+MzM8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0i

Sm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0

aG9yPkJvZHN3b3J0aCwgU2FyYWggTTwvYXV0aG9yPjxhdXRob3I+Q2xhcmUsIElzYWJlbCBDSDwv

YXV0aG9yPjxhdXRob3I+U2ltYmxldHQsIFNhcmEgSzwvYXV0aG9yPjxhdXRob3I+RGVhZmJsaW5k

IFVLPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkRlYWZi

bGluZG5lc3MgYW5kIG1lbnRhbCBoZWFsdGg6IFBzeWNob2xvZ2ljYWwgZGlzdHJlc3MgYW5kIHVu

bWV0IG5lZWQgYW1vbmcgYWR1bHRzIHdpdGggZHVhbCBzZW5zb3J5IGltcGFpcm1lbnQ8L3RpdGxl

PjxzZWNvbmRhcnktdGl0bGU+QnJpdGlzaCBKb3VybmFsIG9mIFZpc3VhbCBJbXBhaXJtZW50PC9z

ZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+QnJpdGlzaCBK

b3VybmFsIG9mIFZpc3VhbCBJbXBhaXJtZW50PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFn

ZXM+Ni0yNjwvcGFnZXM+PHZvbHVtZT4yOTwvdm9sdW1lPjxudW1iZXI+MTwvbnVtYmVyPjxkYXRl

cz48eWVhcj4yMDExPC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDI2NC02MTk2PC9pc2JuPjx1cmxzPjwv

dXJscz48L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5DaGlhPC9BdXRob3I+PFllYXI+MjAw

NjwvWWVhcj48UmVjTnVtPjQ8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjQ8L3JlYy1udW1i

ZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2

dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+NDwva2V5PjwvZm9yZWln

bi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29u

dHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Q2hpYSwgRWUtTXVubjwvYXV0aG9yPjxhdXRob3I+

TWl0Y2hlbGwsIFBhdWw8L2F1dGhvcj48YXV0aG9yPlJvY2h0Y2hpbmEsIEVsZW5hPC9hdXRob3I+

PGF1dGhvcj5Gb3JhbiwgU3VyaXlhPC9hdXRob3I+PGF1dGhvcj5Hb2xkaW5nLCBNYXJ5YW5uZTwv

YXV0aG9yPjxhdXRob3I+V2FuZywgSmllIEppbjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1

dG9ycz48dGl0bGVzPjx0aXRsZT5Bc3NvY2lhdGlvbiBiZXR3ZWVuIHZpc2lvbiBhbmQgaGVhcmlu

ZyBpbXBhaXJtZW50cyBhbmQgdGhlaXIgY29tYmluZWQgZWZmZWN0cyBvbiBxdWFsaXR5IG9mIGxp

ZmU8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+QXJjaGl2ZXMgb2YgT3BodGhhbG1vbG9neTwvc2Vj

b25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkFyY2hpdmVzIG9m

IE9waHRoYWxtb2xvZ3k8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4xNDY1LTE0NzA8

L3BhZ2VzPjx2b2x1bWU+MTI0PC92b2x1bWU+PG51bWJlcj4xMDwvbnVtYmVyPjxkYXRlcz48eWVh

cj4yMDA2PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDAwMy05OTUwPC9pc2JuPjx1cmxzPjwvdXJscz48

L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5DaG91PC9BdXRob3I+PFllYXI+MjAwNDwvWWVh

cj48UmVjTnVtPjM0PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4zNDwvcmVjLW51bWJlcj48

Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2Rz

N2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3ODQxOTU3Ij4zNDwva2V5PjwvZm9yZWlnbi1r

ZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJp

YnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Q2hvdSwgS2Vl4oCQTGVlPC9hdXRob3I+PGF1dGhvcj5D

aGksIElyaXM8L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PHRpdGxlcz48dGl0bGU+

Q29tYmluZWQgZWZmZWN0IG9mIHZpc2lvbiBhbmQgaGVhcmluZyBpbXBhaXJtZW50IG9uIGRlcHJl

c3Npb24gaW4gZWxkZXJseSBDaGluZXNlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkludGVybmF0

aW9uYWwgam91cm5hbCBvZiBnZXJpYXRyaWMgcHN5Y2hpYXRyeTwvc2Vjb25kYXJ5LXRpdGxlPjwv

dGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkludGVybmF0aW9uYWwgam91cm5hbCBvZiBn

ZXJpYXRyaWMgcHN5Y2hpYXRyeTwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjgyNS04

MzI8L3BhZ2VzPjx2b2x1bWU+MTk8L3ZvbHVtZT48bnVtYmVyPjk8L251bWJlcj48ZGF0ZXM+PHll

YXI+MjAwNDwveWVhcj48L2RhdGVzPjxpc2JuPjEwOTktMTE2NjwvaXNibj48dXJscz48L3VybHM+

PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+Q2FwZWxsYeKAkE1jRG9ubmFsbDwvQXV0aG9y

PjxZZWFyPjIwMDU8L1llYXI+PFJlY051bT4zNTwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+

MzU8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4

OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+MzU8

L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwv

cmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkNhcGVsbGHigJBNY0Rvbm5h

bGwsIE1pY2hlbGUgRTwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0

aXRsZT5UaGUgZWZmZWN0cyBvZiBzaW5nbGUgYW5kIGR1YWwgc2Vuc29yeSBsb3NzIG9uIHN5bXB0

b21zIG9mIGRlcHJlc3Npb24gaW4gdGhlIGVsZGVybHk8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+

SW50ZXJuYXRpb25hbCBqb3VybmFsIG9mIGdlcmlhdHJpYyBwc3ljaGlhdHJ5PC9zZWNvbmRhcnkt

dGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+SW50ZXJuYXRpb25hbCBqb3Vy

bmFsIG9mIGdlcmlhdHJpYyBwc3ljaGlhdHJ5PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFn

ZXM+ODU1LTg2MTwvcGFnZXM+PHZvbHVtZT4yMDwvdm9sdW1lPjxudW1iZXI+OTwvbnVtYmVyPjxk

YXRlcz48eWVhcj4yMDA1PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MTA5OS0xMTY2PC9pc2JuPjx1cmxz

PjwvdXJscz48L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5MdXBzYWtrbzwvQXV0aG9yPjxZ

ZWFyPjIwMDI8L1llYXI+PFJlY051bT4zNjwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+MzY8

L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0

ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+MzY8L2tl

eT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVm

LXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkx1cHNha2tvLCBUYWluYTwvYXV0

aG9yPjxhdXRob3I+TcOkbnR5asOkcnZpLCBNYWlqYTwvYXV0aG9yPjxhdXRob3I+S2F1dGlhaW5l

biwgSGFubnU8L2F1dGhvcj48YXV0aG9yPlN1bGthdmEsIFJhaW1vPC9hdXRob3I+PC9hdXRob3Jz

PjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkNvbWJpbmVkIGhlYXJpbmcgYW5kIHZpc3Vh

bCBpbXBhaXJtZW50IGFuZCBkZXByZXNzaW9uIGluIGEgcG9wdWxhdGlvbiBhZ2VkIDc1IHllYXJz

IGFuZCBvbGRlcjwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5JbnRlcm5hdGlvbmFsIGpvdXJuYWwg

b2YgZ2VyaWF0cmljIHBzeWNoaWF0cnk8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9k

aWNhbD48ZnVsbC10aXRsZT5JbnRlcm5hdGlvbmFsIGpvdXJuYWwgb2YgZ2VyaWF0cmljIHBzeWNo

aWF0cnk8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz44MDgtODEzPC9wYWdlcz48dm9s

dW1lPjE3PC92b2x1bWU+PG51bWJlcj45PC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMDI8L3llYXI+

PC9kYXRlcz48aXNibj4xMDk5LTExNjY8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0

ZT48Q2l0ZT48QXV0aG9yPkhlaW5lPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48UmVjTnVtPjM3

PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4zNzwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlz

PjxrZXkgYXBwPSJFTiIgZGItaWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZz

eCIgdGltZXN0YW1wPSIxNTI3ODQxOTU3Ij4zNzwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlw

ZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRo

b3JzPjxhdXRob3I+SGVpbmUsIENoeXJpc3NlPC9hdXRob3I+PGF1dGhvcj5Ccm93bmluZywgQ29s

ZXR0ZSBKPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPk1l

bnRhbCBoZWFsdGggYW5kIGR1YWwgc2Vuc29yeSBsb3NzIGluIG9sZGVyIGFkdWx0czogYSBzeXN0

ZW1hdGljIHJldmlldzwvdGl0bGU+PHNlY29uZGFyeS10aXRsZT5Gcm9udGllcnMgaW4gYWdpbmcg

bmV1cm9zY2llbmNlPC9zZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwt

dGl0bGU+RnJvbnRpZXJzIGluIGFnaW5nIG5ldXJvc2NpZW5jZTwvZnVsbC10aXRsZT48L3Blcmlv

ZGljYWw+PHBhZ2VzPjgzPC9wYWdlcz48dm9sdW1lPjY8L3ZvbHVtZT48ZGF0ZXM+PHllYXI+MjAx

NDwveWVhcj48L2RhdGVzPjxpc2JuPjE2NjMtNDM2NTwvaXNibj48dXJscz48L3VybHM+PC9yZWNv

cmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+Q29zaDwvQXV0aG9yPjxZZWFyPjIwMTc8L1llYXI+PFJl

Y051bT4zODwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+Mzg8L3JlYy1udW1iZXI+PGZvcmVp

Z24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4

eGQwd3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1NyI+Mzg8L2tleT48L2ZvcmVpZ24ta2V5cz48

cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9y

cz48YXV0aG9ycz48YXV0aG9yPkNvc2gsIFM8L2F1dGhvcj48YXV0aG9yPkhhbm5vLCBUPC9hdXRo

b3I+PGF1dGhvcj5IZWxtZXIsIEM8L2F1dGhvcj48YXV0aG9yPkJlcnRlbHNlbiwgRzwvYXV0aG9y

PjxhdXRob3I+RGVsY291cnQsIEM8L2F1dGhvcj48YXV0aG9yPlNjaGlybWVyLCBIPC9hdXRob3I+

PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPlRoZSBhc3NvY2lhdGlvbiBh

bW9uZ3N0IHZpc3VhbCwgaGVhcmluZywgYW5kIGR1YWwgc2Vuc29yeSBsb3NzIHdpdGggZGVwcmVz

c2lvbiBhbmQgYW54aWV0eSBvdmVyIDYgeWVhcnM6IFRoZSBUcm9tc8O4IFN0dWR5PC90aXRsZT48

c2Vjb25kYXJ5LXRpdGxlPkludGVybmF0aW9uYWwgSm91cm5hbCBvZiBHZXJpYXRyaWMgUHN5Y2hp

YXRyeTwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPklu

dGVybmF0aW9uYWwgam91cm5hbCBvZiBnZXJpYXRyaWMgcHN5Y2hpYXRyeTwvZnVsbC10aXRsZT48

L3BlcmlvZGljYWw+PGRhdGVzPjx5ZWFyPjIwMTc8L3llYXI+PC9kYXRlcz48aXNibj4xMDk5LTEx

NjY8L2lzYm4+PHVybHM+PC91cmxzPjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPkRhdmlk

c29uPC9BdXRob3I+PFllYXI+MjAxNzwvWWVhcj48UmVjTnVtPjM5PC9SZWNOdW0+PHJlY29yZD48

cmVjLW51bWJlcj4zOTwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGIt

aWQ9Inp0ZHZwcng5cXRmZDIwZXd0NXZ2d2RzN2ZlOXh4ZDB3cHZzeCIgdGltZXN0YW1wPSIxNTI3

ODQxOTU3Ij4zOTwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFsIEFy

dGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+RGF2aWRz

b24sIEphY29iIEdTPC9hdXRob3I+PGF1dGhvcj5HdXRocmllLCBEYXduIE08L2F1dGhvcj48L2F1

dGhvcnM+PC9jb250cmlidXRvcnM+PHRpdGxlcz48dGl0bGU+T2xkZXIgYWR1bHRzIHdpdGggYSBj

b21iaW5hdGlvbiBvZiB2aXNpb24gYW5kIGhlYXJpbmcgaW1wYWlybWVudCBleHBlcmllbmNlIGhp

Z2hlciByYXRlcyBvZiBjb2duaXRpdmUgaW1wYWlybWVudCwgZnVuY3Rpb25hbCBkZXBlbmRlbmNl

LCBhbmQgd29yc2Ugb3V0Y29tZXMgYWNyb3NzIGEgc2V0IG9mIHF1YWxpdHkgaW5kaWNhdG9yczwv

dGl0bGU+PHNlY29uZGFyeS10aXRsZT5Kb3VybmFsIG9mIGFnaW5nIGFuZCBoZWFsdGg8L3NlY29u

ZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5Kb3VybmFsIG9mIEFn

aW5nIGFuZCBIZWFsdGg8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4wODk4MjY0MzE3

NzIzNDA3PC9wYWdlcz48ZGF0ZXM+PHllYXI+MjAxNzwveWVhcj48L2RhdGVzPjxpc2JuPjA4OTgt

MjY0MzwvaXNibj48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT4A

ADDIN EN.CITE.DATA [13, 33-39]. Persons with deafblindness often experience barriers to accessing mental health services. For example, in the UK, 60% of persons with deafblindness surveyed reported experiencing psychological distress, while only 5% said that they had access to mental health services ADDIN EN.CITE <EndNote><Cite><Author>Bodsworth</Author><Year>2011</Year><RecNum>33</RecNum><DisplayText>[33]</DisplayText><record><rec-number>33</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">33</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Bodsworth, Sarah M</author><author>Clare, Isabel CH</author><author>Simblett, Sara K</author><author>Deafblind UK</author></authors></contributors><titles><title>Deafblindness and mental health: Psychological distress and unmet need among adults with dual sensory impairment</title><secondary-title>British Journal of Visual Impairment</secondary-title></titles><periodical><full-title>British Journal of Visual Impairment</full-title></periodical><pages>6-26</pages><volume>29</volume><number>1</number><dates><year>2011</year></dates><isbn>0264-6196</isbn><urls></urls></record></Cite></EndNote>[33]. Similarly, in the United States, only 16% of mental health service providers had procedures in place to accommodate persons with deafblindness ADDIN EN.CITE <EndNote><Cite><Author>Wiley</Author><Year>2013</Year><RecNum>40</RecNum><DisplayText>[40]</DisplayText><record><rec-number>40</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">40</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wiley, Susan</author><author>Meinzen-Derr, Jareen</author><author>Stremel-Thomas, Kathleen</author><author>Schalock, Mark</author><author>Bashinski, Susan M</author><author>Ruder, Charlotte</author></authors></contributors><titles><title>Outcomes for children with deaf-blindness with cochlear implants: a multisite observational study</title><secondary-title>Otology &amp; Neurotology</secondary-title></titles><periodical><full-title>Otology &amp; Neurotology</full-title></periodical><pages>507-515</pages><volume>34</volume><number>3</number><dates><year>2013</year></dates><isbn>1531-7129</isbn><urls></urls></record></Cite></EndNote>[40]. Our voiceHealthHigh-incomecountriesLow and middle-income countriesAre the needs of persons with deafblindness?adequately covered by the national health system?55%36%Access to health-specific services 66%27%Particular attention to the sexual and reproductive health and rights of women and men with deafblindness 11%9%The survey indicates that health seems to be more accessible for persons with deafblindness than education, especially in high-income countries. Two-thirds of respondents from high-income countries reported having access to specific health services compared to only 27% in lower-income countries. However, both high and low-income countries are reported to be failing persons with deafblindness in terms of sexual and reproductive health services.Ongoing efforts: Providing early intervention services for infants with sensory impairments in Kenya3218815228282500Sense International launched an early intervention programme in 2017 in partnership with one hospital and three health centres. The three-year programme is piloting the first ever sensory screening and early intervention programme for children aged 0 to 3 years in Kenya. The programme aims to screen 75,000 infants for congenital impairments, provide referrals for children with single sensory impairments, and enrol children with deafblindness in early intervention services, including sensory stimulation and other therapies.Early intervention units were established within a Ministry of Health hospital and three health centres. Health workers and community health volunteers have been trained to administer the first step risk-factor questionnaire. Any child found to be at risk is sent for screening using visual and auditory testing equipment. Trained occupational therapists then test children's vision and hearing. Children receive further referrals and therapy based on their individual needs.Christina Moraa’s son, Simon (pictured), was one of the first children to be tested.? Christina said: “I never suspected that my son had a problem with his hearing. Thankfully, the screening was provided for free, and they have promised support for my child’s assessment and treatment.”The consultation undertaken at the 2018 Helen Keller World Conference provided a more detailed picture of healthcare for persons with deafblindness, highlighting several key issues: Medical professionals lack knowledge about the causes and specificity of deafblindness, particularly in children, which leads to poor early identification and intervention.Healthcare staff also lack knowledge about the specific communication requirements of persons with deafblindness, which often leads to professionals talking to interpreter-guides or family members rather than the person themselves. This can have a serious impact, including misdiagnosis, as the person is unable to explain his or her symptoms. Furthermore, persons with deafblindness are unable to access information about proposed treatment, leading to a limited understanding of their own medical history. In emergency situations, health providers often have no idea how to communicate with a person with deafblindness. This means that the experience can be extremely frightening and/or violating for the person, who does not know what is happening.Health promotion and prevention campaigns, for example on immunisation, non-communicable diseases and HIV/Aids, are often inaccessible.The profound isolation and lack of socialisation experienced by persons with deafblindness can result in severe distress. A lack of adequate mental health support and services exacerbates this issue.WFDB members shared good practice that tackle issues linked to access to health in different countries. Several interesting initiatives emerged, including: In Denmark, the Association for the Deafblind provides its members with personalised cards stipulating their communication requirements and needs. These can then be placed on a hospital bed in case of emergency, alerting providers to their needs. Information kits on deafblindness have also been distributed to health providers.In Sweden, the government has organised a deafblindness ‘team’ to provide support on health, rehabilitation and social inclusion, with a specific focus on mental health.Australia has a national booking service that enables persons with deafblindness to book interpreter-guides when using health facilities. Whilst effective, this system works better in private than public practice.In Mexico, a training course has been developed to support interactions between nurses and persons with deafblindness. A training workshop on basic communications systems has also been offered to student nurses at the university. Due to its success, the approach will be replicated in the future.In Tanzania, Romania, Kenya, Uganda, and India, Sense international has developed early detection and intervention programs (see page XX). In Malawi, VIHEMA Deafblind has led a pilot project on access to sexual and reproductive health (see page XX). RecommendationsProvide adequate training to healthcare staff both on the causes of deafblindness and the specific communication requirements of persons with deafblindness.Ensure access to adequate sexual and reproductive health services, with an emphasis on women and girls with deafblindness.Ensure the provision of adequate early detection and intervention services, in partnership with education providers.Ensure the adequate provision of interpreter-guides.Ongoing efforts: Persons with deafblindness and sexual reproductive health in MalawiMalawi ratified the CRPD and has endorsed the SDGs. However, not all beneficiaries of the charters are being reached accordingly. Amongst the most vulnerable are persons with deafblindness, and in particular women and girls. They experience a lack of access to health services and facilities, health information and communication support, and experience negative attitudes from health workers. This often means that women and girls do not visit health services. They are also exposed to gender-based violence and unwanted pregnancy. This is why VIHEMA Deafblind Malawi has started advocating for Sexual Reproductive Health Services (SRH) and family planning to be more accessible for women and girls with deafblindness.VIHEMA carried out a pilot programme that provides training for women with deafblindness and their families, as well for health professionals, including midwives, clinicians and environmental health assistants. Health workers were trained to more effectively communicate about sexual and reproductive health, and given relevant information on supporting women and girls with deafblindness. Before the training, women and girls with deafblindness did not go to health centres due to staff not being able to communicate and the negative attitude of some workers. The twin track approach embedded helped to break down some of the barriers and facilitate access. A number of women with deafblindness have also proactively engaged in discussions with women without disabilities about family planning. The project also tackled the incorrect belief that forced sterilisation protects women with disabilities from sexual violence. Whilst the project has achieved positive results, our advocacy work continues, as further changes are needed in both the policies and protocols of the healthcare system in Malawi. Progress will ensure the inclusion of persons with disabilities, especially persons with deafblindness.Persons with deafblindness and participation in political and public lifePolitical participationHigh-incomecountriesUpper-middle income countriesLower-income countriesLaws in place restricting the right to vote or to be elected 17020Active support to engage in political participation171725The survey found that, whilst few countries legally restrict the right to vote of persons with deafblindness, few actually provide support to enable political participation. At the 2018 Helen Keller World Conference, WFDB members were keen to share their experiences about political participation and engagement in public life. There is an acute perception that this is the only way to ensure that persons with deafblindness are recognised and get the attention they deserve and the services they require. Discussions were focused on the key issues in three domains: voting rights and accessibility, personal engagement in consultative mechanisms and beyond, and the development of DPOs.Voting rights and accessibility:Accessibility is a key issue in terms of political participation, both with regards to access to information about parties and their programmes, and the day of an election itself.In the majority of countries, no interpretation is provided on televised news or during political debates, preventing persons with deafblindness from making informed decisions. As a consequence, persons with deafblindness have access to limited political information. Many often do not even know the names of political parties or what they stand for. In turn, this reinforces existing prejudices among some families that persons with deafblindness are unable to vote. Voting ballots are often inaccessible. Where they are accessible, persons with deafblindness do not always have access to the right support to be able to vote. Political representation of persons with deafblindness: Persons with deafblindness are not adequately represented in politics at all levels. There is a lack of persons with deafblindness elected or appointed within the political arena. People face prejudices from people without disabilities and persons with other disabilities. Development of DPOs of persons with deafblindness:Many WFDB members expressed their frustration with the lack of recognition of organisations of persons with deafblindness, both by governments and disability movements. Whilst some countries have made progress, there is not yet true and full recognition of persons with deafblindness. As a result, there is little support and funding to enable people to participate in the political process. In our own words: The importance of participation of deafblind persons in the advancement of public policies at local level, S?o Paulo, Brazil. Eulália Alves Cordeiro“My name is Eulália Alves Cordeiro. I am a person with deafblindness. I’m a counsellor at the Municipal Counsel of the Persons with Disabilities in the capital of S?o Paulo.“Since 2002, persons with deafblindness from the Brazilian Association of Persons with Deafblindness (named ABRASC) started to participate directly in the Municipal Counsel of the Persons with Disabilities. This engagement increased the visibility of deafblindness, giving participants the chance to express themselves, fight for their rights, and to use their voice to show that they were able to actively take part in public politics in the same way that other persons with disabilities are able to. However, deafblindness still doesn’t have a specific seat at the table. Indeed,?deafblind persons usually take over alternatively the chair of the deaf persons, the blind persons or the group of persons with multiple disability. “As of December 2017, seven deafblind persons work as counsellors or participate in working groups across three Brazilian cities. They work in different sectors related not only to discussions on disability policies, but also on policies for women and health, among other issues.“Across many states in Brazil, persons with deafblindness are unable to rely on the provision of interpreter-guide services at schools and universities. As a result of our advocacy work.” S?o Paulo, however, is the only city that provides interpreter-guide services for persons with deafblindness, guaranteed by a municipal ordinance.Beyond the many challenges identified, WFDB members shared several encouraging developments and initiatives: In Croatia, the country’s deafblind association asked for and received financing from the government to provide deafblind interpreters on the day of an election. Voting lists were made accessible, in large print and braille formats. Persons with deafblindness were also given information on the different parties and programmes. In addition, a person with deafblindness has been elected to the country’s parliament. In the upcoming election in Sweden, persons with deafblindness who communicate using braille will automatically receive information about the election, as well as their voting card, in braille. In India, significant advocacy work has taken place with the Electoral Commission, notably inviting them to train persons with deafblindness on election procedures and the use of the voting machine. Such interaction has raised awareness among officials, who have since taken steps to increase the accessibility of elections. On Helen Keller Day 2018, Sense International India received news from the Election Commission that people with deafblindness will be included within the electoral process for the first time. Accessibility will be improved so that adults with deafblindness can participate in forthcoming general elections.In Malawi, the Electoral Commission introduced a tactile ballot. However, there is still room for improvement and the introduction of more features for persons with deafblindness. In S?o Paulo, Brazil, persons with deafblindness have been actively involved in the municipal council (see page XX).In Denmark, the country’s organisation of persons with deafblindness disseminates a twice-yearly magazine to inform policymakers and politicians about the key issues faced by persons with deafblindness, as well as their key needs and demands. RecommendationsEnsure that the right to vote is granted to all persons with deafblindness. Take into consideration the accessibility requirements of persons with deafblindness with regards to election campaigns, voting materials and polling stations. Support the engagement of persons with deafblindness in political and public life. Support organisations of persons with deafblindness and involve them as a distinct disability group in all consultations with disability movements.Focus on: Participation in political and public lifeCountry: Kenya44367455715000The enjoyment of political rights, including the right to vote and to be elected, is an important aspect of participation in political and public life. Persons with deafblindness are often excluded from decision-making processes and positions of authority in government, the workplace and public life more generally. It is extremely rare for persons with deafblindness to stand for elections, hold office or perform public functions at any level of government. 42672001162685Image SEQ Figure \* ARABIC 1. Emma Mbugua00Image SEQ Figure \* ARABIC 1. Emma MbuguaHowever, Emma Mbugua, a woman with deafblindness, served as a member of the county assembly for Nakuru County from 2013 to 2017. In Kenya, persons with disabilities are increasingly represented in both local and national public offices. This is in part thanks to legislation which prescribes that persons with disabilities should fill 5% of all public positions.Ms Mbugua has long been an active advocate for disability rights in Kenya, working on a range of issues, including education and voting rights, for many years prior to taking office. It was through this work that she first came into contact with the Jubilee Party, which nominated her to serve as a member for the county assembly. At first, Emma covered the costs of employing a personal assistant to support her inclusion in processes related to her duties. However, the county eventually agreed to pay for assistive devices and an assistant to support mobility, access to documents, and participation in assembly debates. County officials were also sensitised to increase their understanding of how they could support her.-571508064500With the support of Sense International, Emma successfully sponsored the 2014 Nakuru County Persons with Disabilities Bill. The Bill was made into an Act and Emma has since worked on its implementation. Emma has demonstrated that persons with deafblindness can engage effectively in public life and has helped to break the stigma that prevents many persons with disabilities from participating in government. Image 2. Emma presents an award to a group of young people at a local football tournamentCase study and contact details: Sense International Kenya, Edwin Osundwa, edwin@senseint-Persons with deafblindness and social lifeThe country-level analyses provided minimal information on social life, with the exception of marital status and the presence of biological parents in the household where children were present. People with deafblindness are less likely to be married than people without disabilities in all datasets except Sudan and Uruguay. Figure 14.Women with deafblindness were much less likely to be married than men with deafblindness in each dataset, even after accounting for age (see Figure 15). Women with deafblindness were also statistically less likely to be married than women with other disabilities across the five datasets, and less likely to be married than women without disabilities in all datasets.Figure 15. Marital status among women and men with deafblindnessAmong those aged under 18 years, children with deafblindness were statistically more likely to have at least one biological parent absent from their household in five of nine datasets (South Africa, Sudan, United States, Mexico and Indonesia) (see Figure 16). Compared to children with other disabilities, most datasets did not show any statistically significant differences, with the exception of Sudan and Indonesia, where children with deafblindness were more likely to be living without at least one parent. Figure 16. Proportion of children aged 5 to 17 years with one or both biological parents absent from the householdThe literature review included several studies that explored other indicators related to social life among persons with deafblindness. These were mostly from high-income countries and among older adults. For example, several studies among older adults with deafblindness found that many experienced decreased participation in everyday activities PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYXJhZGE8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS

ZWNOdW0+NTwvUmVjTnVtPjxEaXNwbGF5VGV4dD5bMTQsIDQxLTQzXTwvRGlzcGxheVRleHQ+PHJl

Y29yZD48cmVjLW51bWJlcj41PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVO

IiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9

IjE1Mjc4NDE5NTciPjU8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5h

bCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkhh

cmFkYSwgU2VpPC9hdXRob3I+PGF1dGhvcj5OaXNoaXdha2ksIFl1amk8L2F1dGhvcj48YXV0aG9y

Pk1pY2hpa2F3YSwgVGFrZWhpcm88L2F1dGhvcj48YXV0aG9yPktpa3VjaGksIFl1cmlrbzwvYXV0

aG9yPjxhdXRob3I+SXdhc2F3YSwgU2F0b2tvPC9hdXRob3I+PGF1dGhvcj5OYWthbm8sIE1ha2lr

bzwvYXV0aG9yPjxhdXRob3I+SXNoaWdhbWksIEFpPC9hdXRob3I+PGF1dGhvcj5TYWl0bywgSGlk

ZXl1a2k8L2F1dGhvcj48YXV0aG9yPlRha2ViYXlhc2hpLCBUb3J1PC9hdXRob3I+PC9hdXRob3Jz

PjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkdlbmRlciBkaWZmZXJlbmNlIGluIHRoZSBy

ZWxhdGlvbnNoaXBzIGJldHdlZW4gdmlzaW9uIGFuZCBoZWFyaW5nIGltcGFpcm1lbnRzIGFuZCBu

ZWdhdGl2ZSB3ZWxsLWJlaW5nPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPlByZXZlbnRpdmUgbWVk

aWNpbmU8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5Q

cmV2ZW50aXZlIG1lZGljaW5lPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+NDMzLTQz

NzwvcGFnZXM+PHZvbHVtZT40Nzwvdm9sdW1lPjxudW1iZXI+NDwvbnVtYmVyPjxkYXRlcz48eWVh

cj4yMDA4PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDA5MS03NDM1PC9pc2JuPjx1cmxzPjwvdXJscz48

L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5UaXdhbmE8L0F1dGhvcj48WWVhcj4yMDE2PC9Z

ZWFyPjxSZWNOdW0+NDE8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjQxPC9yZWMtbnVtYmVy

Pjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3

ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTciPjQxPC9rZXk+PC9mb3JlaWdu

LWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250

cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5UaXdhbmEsIFJ1bWFuZGVlcDwvYXV0aG9yPjxhdXRo

b3I+QmVuYm93LCBTdXNhbiBNYXJ5PC9hdXRob3I+PGF1dGhvcj5LaW5nc3RvbiwgUGF1bDwvYXV0

aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5MYXRlIGxpZmUgYWNx

dWlyZWQgZHVhbC1zZW5zb3J5IGltcGFpcm1lbnQ6IEEgc3lzdGVtYXRpYyByZXZpZXcgb2YgaXRz

IGltcGFjdCBvbiBldmVyeWRheSBjb21wZXRlbmNlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkJy

aXRpc2ggSm91cm5hbCBvZiBWaXN1YWwgSW1wYWlybWVudDwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0

bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkJyaXRpc2ggSm91cm5hbCBvZiBWaXN1YWwgSW1w

YWlybWVudDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjIwMy0yMTM8L3BhZ2VzPjx2

b2x1bWU+MzQ8L3ZvbHVtZT48bnVtYmVyPjM8L251bWJlcj48ZGF0ZXM+PHllYXI+MjAxNjwveWVh

cj48L2RhdGVzPjxpc2JuPjAyNjQtNjE5NjwvaXNibj48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9D

aXRlPjxDaXRlPjxBdXRob3I+QnJlbm5hbjwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+PFJlY051

bT40MjwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+NDI8L3JlYy1udW1iZXI+PGZvcmVpZ24t

a2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQw

d3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1OCI+NDI8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVm

LXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48

YXV0aG9ycz48YXV0aG9yPkJyZW5uYW4sIE1hcms8L2F1dGhvcj48YXV0aG9yPlN1LCBZYS1waW5n

PC9hdXRob3I+PGF1dGhvcj5Ib3Jvd2l0eiwgQW15PC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJp

YnV0b3JzPjx0aXRsZXM+PHRpdGxlPkxvbmdpdHVkaW5hbCBhc3NvY2lhdGlvbnMgYmV0d2VlbiBk

dWFsIHNlbnNvcnkgaW1wYWlybWVudCBhbmQgZXZlcnlkYXkgY29tcGV0ZW5jZSBhbW9uZyBvbGRl

ciBhZHVsdHM8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+Sm91cm5hbCBvZiByZWhhYmlsaXRhdGlv

biByZXNlYXJjaCBhbmQgZGV2ZWxvcG1lbnQ8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVy

aW9kaWNhbD48ZnVsbC10aXRsZT5Kb3VybmFsIG9mIHJlaGFiaWxpdGF0aW9uIHJlc2VhcmNoIGFu

ZCBkZXZlbG9wbWVudDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjc3NzwvcGFnZXM+

PHZvbHVtZT40Mzwvdm9sdW1lPjxudW1iZXI+NjwvbnVtYmVyPjxkYXRlcz48eWVhcj4yMDA2PC95

ZWFyPjwvZGF0ZXM+PGlzYm4+MDc0OC03NzExPC9pc2JuPjx1cmxzPjwvdXJscz48L3JlY29yZD48

L0NpdGU+PENpdGU+PEF1dGhvcj5Nb2xsZXI8L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxSZWNO

dW0+MTY8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2PC9yZWMtbnVtYmVyPjxmb3JlaWdu

LWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhk

MHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTciPjE2PC9rZXk+PC9mb3JlaWduLWtleXM+PHJl

Zi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+

PGF1dGhvcnM+PGF1dGhvcj5Nb2xsZXIsIENsYWVzPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJp

YnV0b3JzPjx0aXRsZXM+PHRpdGxlPkRlYWZibGluZG5lc3M6IGxpdmluZyB3aXRoIHNlbnNvcnkg

ZGVwcml2YXRpb248L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+VGhlIExhbmNldDwvc2Vjb25kYXJ5

LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPlRoZSBMYW5jZXQ8L2Z1bGwt

dGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz5zNDYtczQ3PC9wYWdlcz48dm9sdW1lPjM2Mjwvdm9s

dW1lPjxkYXRlcz48eWVhcj4yMDAzPC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDE0MC02NzM2PC9pc2Ju

Pjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+PC9FbmROb3RlPgB=

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IYXJhZGE8L0F1dGhvcj48WWVhcj4yMDA4PC9ZZWFyPjxS

ZWNOdW0+NTwvUmVjTnVtPjxEaXNwbGF5VGV4dD5bMTQsIDQxLTQzXTwvRGlzcGxheVRleHQ+PHJl

Y29yZD48cmVjLW51bWJlcj41PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVO

IiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9

IjE1Mjc4NDE5NTciPjU8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5h

bCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkhh

cmFkYSwgU2VpPC9hdXRob3I+PGF1dGhvcj5OaXNoaXdha2ksIFl1amk8L2F1dGhvcj48YXV0aG9y

Pk1pY2hpa2F3YSwgVGFrZWhpcm88L2F1dGhvcj48YXV0aG9yPktpa3VjaGksIFl1cmlrbzwvYXV0

aG9yPjxhdXRob3I+SXdhc2F3YSwgU2F0b2tvPC9hdXRob3I+PGF1dGhvcj5OYWthbm8sIE1ha2lr

bzwvYXV0aG9yPjxhdXRob3I+SXNoaWdhbWksIEFpPC9hdXRob3I+PGF1dGhvcj5TYWl0bywgSGlk

ZXl1a2k8L2F1dGhvcj48YXV0aG9yPlRha2ViYXlhc2hpLCBUb3J1PC9hdXRob3I+PC9hdXRob3Jz

PjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPkdlbmRlciBkaWZmZXJlbmNlIGluIHRoZSBy

ZWxhdGlvbnNoaXBzIGJldHdlZW4gdmlzaW9uIGFuZCBoZWFyaW5nIGltcGFpcm1lbnRzIGFuZCBu

ZWdhdGl2ZSB3ZWxsLWJlaW5nPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPlByZXZlbnRpdmUgbWVk

aWNpbmU8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5Q

cmV2ZW50aXZlIG1lZGljaW5lPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+NDMzLTQz

NzwvcGFnZXM+PHZvbHVtZT40Nzwvdm9sdW1lPjxudW1iZXI+NDwvbnVtYmVyPjxkYXRlcz48eWVh

cj4yMDA4PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDA5MS03NDM1PC9pc2JuPjx1cmxzPjwvdXJscz48

L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5UaXdhbmE8L0F1dGhvcj48WWVhcj4yMDE2PC9Z

ZWFyPjxSZWNOdW0+NDE8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjQxPC9yZWMtbnVtYmVy

Pjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3

ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTciPjQxPC9rZXk+PC9mb3JlaWdu

LWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250

cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5UaXdhbmEsIFJ1bWFuZGVlcDwvYXV0aG9yPjxhdXRo

b3I+QmVuYm93LCBTdXNhbiBNYXJ5PC9hdXRob3I+PGF1dGhvcj5LaW5nc3RvbiwgUGF1bDwvYXV0

aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5MYXRlIGxpZmUgYWNx

dWlyZWQgZHVhbC1zZW5zb3J5IGltcGFpcm1lbnQ6IEEgc3lzdGVtYXRpYyByZXZpZXcgb2YgaXRz

IGltcGFjdCBvbiBldmVyeWRheSBjb21wZXRlbmNlPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkJy

aXRpc2ggSm91cm5hbCBvZiBWaXN1YWwgSW1wYWlybWVudDwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0

bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkJyaXRpc2ggSm91cm5hbCBvZiBWaXN1YWwgSW1w

YWlybWVudDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjIwMy0yMTM8L3BhZ2VzPjx2

b2x1bWU+MzQ8L3ZvbHVtZT48bnVtYmVyPjM8L251bWJlcj48ZGF0ZXM+PHllYXI+MjAxNjwveWVh

cj48L2RhdGVzPjxpc2JuPjAyNjQtNjE5NjwvaXNibj48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9D

aXRlPjxDaXRlPjxBdXRob3I+QnJlbm5hbjwvQXV0aG9yPjxZZWFyPjIwMDY8L1llYXI+PFJlY051

bT40MjwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+NDI8L3JlYy1udW1iZXI+PGZvcmVpZ24t

a2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQw

d3B2c3giIHRpbWVzdGFtcD0iMTUyNzg0MTk1OCI+NDI8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVm

LXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48

YXV0aG9ycz48YXV0aG9yPkJyZW5uYW4sIE1hcms8L2F1dGhvcj48YXV0aG9yPlN1LCBZYS1waW5n

PC9hdXRob3I+PGF1dGhvcj5Ib3Jvd2l0eiwgQW15PC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJp

YnV0b3JzPjx0aXRsZXM+PHRpdGxlPkxvbmdpdHVkaW5hbCBhc3NvY2lhdGlvbnMgYmV0d2VlbiBk

dWFsIHNlbnNvcnkgaW1wYWlybWVudCBhbmQgZXZlcnlkYXkgY29tcGV0ZW5jZSBhbW9uZyBvbGRl

ciBhZHVsdHM8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+Sm91cm5hbCBvZiByZWhhYmlsaXRhdGlv

biByZXNlYXJjaCBhbmQgZGV2ZWxvcG1lbnQ8L3NlY29uZGFyeS10aXRsZT48L3RpdGxlcz48cGVy

aW9kaWNhbD48ZnVsbC10aXRsZT5Kb3VybmFsIG9mIHJlaGFiaWxpdGF0aW9uIHJlc2VhcmNoIGFu

ZCBkZXZlbG9wbWVudDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjc3NzwvcGFnZXM+

PHZvbHVtZT40Mzwvdm9sdW1lPjxudW1iZXI+NjwvbnVtYmVyPjxkYXRlcz48eWVhcj4yMDA2PC95

ZWFyPjwvZGF0ZXM+PGlzYm4+MDc0OC03NzExPC9pc2JuPjx1cmxzPjwvdXJscz48L3JlY29yZD48

L0NpdGU+PENpdGU+PEF1dGhvcj5Nb2xsZXI8L0F1dGhvcj48WWVhcj4yMDAzPC9ZZWFyPjxSZWNO

dW0+MTY8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2PC9yZWMtbnVtYmVyPjxmb3JlaWdu

LWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhk

MHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTciPjE2PC9rZXk+PC9mb3JlaWduLWtleXM+PHJl

Zi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+

PGF1dGhvcnM+PGF1dGhvcj5Nb2xsZXIsIENsYWVzPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJp

YnV0b3JzPjx0aXRsZXM+PHRpdGxlPkRlYWZibGluZG5lc3M6IGxpdmluZyB3aXRoIHNlbnNvcnkg

ZGVwcml2YXRpb248L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+VGhlIExhbmNldDwvc2Vjb25kYXJ5

LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPlRoZSBMYW5jZXQ8L2Z1bGwt

dGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz5zNDYtczQ3PC9wYWdlcz48dm9sdW1lPjM2Mjwvdm9s

dW1lPjxkYXRlcz48eWVhcj4yMDAzPC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDE0MC02NzM2PC9pc2Ju

Pjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+PC9FbmROb3RlPgB=

ADDIN EN.CITE.DATA [14, 41-43]. A study of older adults with deafblindness in Sweden found that some people chose not to participate in physical activity due to stigma, low self-esteem or other responsibilities, such as contacting health and welfare agencies ADDIN EN.CITE <EndNote><Cite><Author>Moller</Author><Year>2003</Year><RecNum>16</RecNum><DisplayText>[43]</DisplayText><record><rec-number>16</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">16</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Moller, Claes</author></authors></contributors><titles><title>Deafblindness: living with sensory deprivation</title><secondary-title>The Lancet</secondary-title></titles><periodical><full-title>The Lancet</full-title></periodical><pages>s46-s47</pages><volume>362</volume><dates><year>2003</year></dates><isbn>0140-6736</isbn><urls></urls></record></Cite></EndNote>[43]. Social isolation among persons with deafblindness was also a common theme in the literature. Across the 11 European countries, adults aged over 50 with deafblindness were twice as likely to be socially inactive compared to people without sensory difficulties ADDIN EN.CITE <EndNote><Cite><Author>Viljanen</Author><Year>2014</Year><RecNum>9</RecNum><DisplayText>[18]</DisplayText><record><rec-number>9</rec-number><foreign-keys><key app="EN" db-id="ztdvprx9qtfd20ewt5vvwds7fe9xxd0wpvsx" timestamp="1527841957">9</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Viljanen, Anne</author><author>T?rm?kangas, Timo</author><author>Vestergaard, Sonja</author><author>Andersen-Ranberg, Karen</author></authors></contributors><titles><title>Dual sensory loss and social participation in older Europeans</title><secondary-title>European Journal of Ageing</secondary-title></titles><periodical><full-title>European Journal of Ageing</full-title></periodical><pages>155-167</pages><volume>11</volume><number>2</number><dates><year>2014</year></dates><isbn>1613-9372</isbn><urls></urls></record></Cite></EndNote>[18]. Challenges to understanding and being understood by others were major barriers to social inclusion, which also contributed to fatigue, frustration and stress. Several studies reported a lower quality of life and wellbeing among older adults with acquired deafblindness PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGlhPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48UmVj

TnVtPjQ8L1JlY051bT48RGlzcGxheVRleHQ+WzEzLCA0NCwgNDVdPC9EaXNwbGF5VGV4dD48cmVj

b3JkPjxyZWMtbnVtYmVyPjQ8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4i

IGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0i

MTUyNzg0MTk1NyI+NDwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFs

IEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Q2hp

YSwgRWUtTXVubjwvYXV0aG9yPjxhdXRob3I+TWl0Y2hlbGwsIFBhdWw8L2F1dGhvcj48YXV0aG9y

PlJvY2h0Y2hpbmEsIEVsZW5hPC9hdXRob3I+PGF1dGhvcj5Gb3JhbiwgU3VyaXlhPC9hdXRob3I+

PGF1dGhvcj5Hb2xkaW5nLCBNYXJ5YW5uZTwvYXV0aG9yPjxhdXRob3I+V2FuZywgSmllIEppbjwv

YXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5Bc3NvY2lhdGlv

biBiZXR3ZWVuIHZpc2lvbiBhbmQgaGVhcmluZyBpbXBhaXJtZW50cyBhbmQgdGhlaXIgY29tYmlu

ZWQgZWZmZWN0cyBvbiBxdWFsaXR5IG9mIGxpZmU8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+QXJj

aGl2ZXMgb2YgT3BodGhhbG1vbG9neTwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2Rp

Y2FsPjxmdWxsLXRpdGxlPkFyY2hpdmVzIG9mIE9waHRoYWxtb2xvZ3k8L2Z1bGwtdGl0bGU+PC9w

ZXJpb2RpY2FsPjxwYWdlcz4xNDY1LTE0NzA8L3BhZ2VzPjx2b2x1bWU+MTI0PC92b2x1bWU+PG51

bWJlcj4xMDwvbnVtYmVyPjxkYXRlcz48eWVhcj4yMDA2PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDAw

My05OTUwPC9pc2JuPjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5M

ZWhhbmU8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxSZWNOdW0+NDM8L1JlY051bT48cmVjb3Jk

PjxyZWMtbnVtYmVyPjQzPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBk

Yi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1

Mjc4NDE5NTgiPjQzPC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwg

QXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5MZWhh

bmUsIENocmlzdGluZSBNPC9hdXRob3I+PGF1dGhvcj5EYW1tZXllciwgSmVzcGVyPC9hdXRob3I+

PGF1dGhvcj5Ib3ZhbGR0LCBIYW5uYSBCPC9hdXRob3I+PGF1dGhvcj5FbHNhc3MsIFBldGVyPC9h

dXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPlNleHVhbGl0eSBh

bmQgd2VsbC1iZWluZyBhbW9uZyBjb3VwbGVzIGxpdmluZyB3aXRoIGFjcXVpcmVkIGRlYWZibGlu

ZG5lc3M8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+U2V4dWFsaXR5IGFuZCBEaXNhYmlsaXR5PC9z

ZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+U2V4dWFsaXR5

IGFuZCBEaXNhYmlsaXR5PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+MTM1LTE0Njwv

cGFnZXM+PHZvbHVtZT4zNTwvdm9sdW1lPjxudW1iZXI+MjwvbnVtYmVyPjxkYXRlcz48eWVhcj4y

MDE3PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDE0Ni0xMDQ0PC9pc2JuPjx1cmxzPjwvdXJscz48L3Jl

Y29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5MZWhhbmU8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFy

PjxSZWNOdW0+NDQ8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjQ0PC9yZWMtbnVtYmVyPjxm

b3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3

ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTgiPjQ0PC9rZXk+PC9mb3JlaWduLWtl

eXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmli

dXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5MZWhhbmUsIENocmlzdGluZSBNPC9hdXRob3I+PGF1dGhv

cj5FbHNhc3MsIFBldGVyPC9hdXRob3I+PGF1dGhvcj5Ib3ZhbGR0LCBIYW5uYSBCPC9hdXRob3I+

PGF1dGhvcj5EYW1tZXllciwgSmVzcGVyPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3Jz

Pjx0aXRsZXM+PHRpdGxlPkEgcmVsYXRpb25zaGlwLWZvY3VzZWQgaW52ZXN0aWdhdGlvbiBvZiBz

cG91c2FsIHBzeWNob2xvZ2ljYWwgYWRqdXN0bWVudCB0byBkdWFsLXNlbnNvcnkgbG9zczwvdGl0

bGU+PHNlY29uZGFyeS10aXRsZT5BZ2luZyAmYW1wOyBtZW50YWwgaGVhbHRoPC9zZWNvbmRhcnkt

dGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+QWdpbmcgJmFtcDsgbWVudGFs

IGhlYWx0aDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjEtODwvcGFnZXM+PGRhdGVz

Pjx5ZWFyPjIwMTY8L3llYXI+PC9kYXRlcz48aXNibj4xMzYwLTc4NjM8L2lzYm4+PHVybHM+PC91

cmxzPjwvcmVjb3JkPjwvQ2l0ZT48L0VuZE5vdGU+AG==

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaGlhPC9BdXRob3I+PFllYXI+MjAwNjwvWWVhcj48UmVj

TnVtPjQ8L1JlY051bT48RGlzcGxheVRleHQ+WzEzLCA0NCwgNDVdPC9EaXNwbGF5VGV4dD48cmVj

b3JkPjxyZWMtbnVtYmVyPjQ8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4i

IGRiLWlkPSJ6dGR2cHJ4OXF0ZmQyMGV3dDV2dndkczdmZTl4eGQwd3B2c3giIHRpbWVzdGFtcD0i

MTUyNzg0MTk1NyI+NDwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3VybmFs

IEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+Q2hp

YSwgRWUtTXVubjwvYXV0aG9yPjxhdXRob3I+TWl0Y2hlbGwsIFBhdWw8L2F1dGhvcj48YXV0aG9y

PlJvY2h0Y2hpbmEsIEVsZW5hPC9hdXRob3I+PGF1dGhvcj5Gb3JhbiwgU3VyaXlhPC9hdXRob3I+

PGF1dGhvcj5Hb2xkaW5nLCBNYXJ5YW5uZTwvYXV0aG9yPjxhdXRob3I+V2FuZywgSmllIEppbjwv

YXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5Bc3NvY2lhdGlv

biBiZXR3ZWVuIHZpc2lvbiBhbmQgaGVhcmluZyBpbXBhaXJtZW50cyBhbmQgdGhlaXIgY29tYmlu

ZWQgZWZmZWN0cyBvbiBxdWFsaXR5IG9mIGxpZmU8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+QXJj

aGl2ZXMgb2YgT3BodGhhbG1vbG9neTwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2Rp

Y2FsPjxmdWxsLXRpdGxlPkFyY2hpdmVzIG9mIE9waHRoYWxtb2xvZ3k8L2Z1bGwtdGl0bGU+PC9w

ZXJpb2RpY2FsPjxwYWdlcz4xNDY1LTE0NzA8L3BhZ2VzPjx2b2x1bWU+MTI0PC92b2x1bWU+PG51

bWJlcj4xMDwvbnVtYmVyPjxkYXRlcz48eWVhcj4yMDA2PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDAw

My05OTUwPC9pc2JuPjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5M

ZWhhbmU8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFyPjxSZWNOdW0+NDM8L1JlY051bT48cmVjb3Jk

PjxyZWMtbnVtYmVyPjQzPC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBk

Yi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1

Mjc4NDE5NTgiPjQzPC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwg

QXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5MZWhh

bmUsIENocmlzdGluZSBNPC9hdXRob3I+PGF1dGhvcj5EYW1tZXllciwgSmVzcGVyPC9hdXRob3I+

PGF1dGhvcj5Ib3ZhbGR0LCBIYW5uYSBCPC9hdXRob3I+PGF1dGhvcj5FbHNhc3MsIFBldGVyPC9h

dXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRpdGxlPlNleHVhbGl0eSBh

bmQgd2VsbC1iZWluZyBhbW9uZyBjb3VwbGVzIGxpdmluZyB3aXRoIGFjcXVpcmVkIGRlYWZibGlu

ZG5lc3M8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+U2V4dWFsaXR5IGFuZCBEaXNhYmlsaXR5PC9z

ZWNvbmRhcnktdGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+U2V4dWFsaXR5

IGFuZCBEaXNhYmlsaXR5PC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+MTM1LTE0Njwv

cGFnZXM+PHZvbHVtZT4zNTwvdm9sdW1lPjxudW1iZXI+MjwvbnVtYmVyPjxkYXRlcz48eWVhcj4y

MDE3PC95ZWFyPjwvZGF0ZXM+PGlzYm4+MDE0Ni0xMDQ0PC9pc2JuPjx1cmxzPjwvdXJscz48L3Jl

Y29yZD48L0NpdGU+PENpdGU+PEF1dGhvcj5MZWhhbmU8L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFy

PjxSZWNOdW0+NDQ8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjQ0PC9yZWMtbnVtYmVyPjxm

b3JlaWduLWtleXM+PGtleSBhcHA9IkVOIiBkYi1pZD0ienRkdnByeDlxdGZkMjBld3Q1dnZ3ZHM3

ZmU5eHhkMHdwdnN4IiB0aW1lc3RhbXA9IjE1Mjc4NDE5NTgiPjQ0PC9rZXk+PC9mb3JlaWduLWtl

eXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmli

dXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5MZWhhbmUsIENocmlzdGluZSBNPC9hdXRob3I+PGF1dGhv

cj5FbHNhc3MsIFBldGVyPC9hdXRob3I+PGF1dGhvcj5Ib3ZhbGR0LCBIYW5uYSBCPC9hdXRob3I+

PGF1dGhvcj5EYW1tZXllciwgSmVzcGVyPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3Jz

Pjx0aXRsZXM+PHRpdGxlPkEgcmVsYXRpb25zaGlwLWZvY3VzZWQgaW52ZXN0aWdhdGlvbiBvZiBz

cG91c2FsIHBzeWNob2xvZ2ljYWwgYWRqdXN0bWVudCB0byBkdWFsLXNlbnNvcnkgbG9zczwvdGl0

bGU+PHNlY29uZGFyeS10aXRsZT5BZ2luZyAmYW1wOyBtZW50YWwgaGVhbHRoPC9zZWNvbmRhcnkt

dGl0bGU+PC90aXRsZXM+PHBlcmlvZGljYWw+PGZ1bGwtdGl0bGU+QWdpbmcgJmFtcDsgbWVudGFs

IGhlYWx0aDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjEtODwvcGFnZXM+PGRhdGVz

Pjx5ZWFyPjIwMTY8L3llYXI+PC9kYXRlcz48aXNibj4xMzYwLTc4NjM8L2lzYm4+PHVybHM+PC91

cmxzPjwvcmVjb3JkPjwvQ2l0ZT48L0VuZE5vdGU+AG==

ADDIN EN.CITE.DATA [13, 44, 45].Our voice Community inclusionHigh-incomecountriesUpper-middle income countriesLow-income countriesAccess to regular community services 50%50%40%Community support services provided83%33%20%Unsurprisingly considering the issues highlighted with regards to the inaccessibility of interpreter-guides, only half of all respondents from high and middle-income countries (and 40% of those from low-income countries) stated that they had access to regular community services. Discussions with WFDB members showed that accessing such services was only possible with the support of family members and that autonomous use was a serious problem. With regards to specific community support services aside from interpreter-guides, 85% of respondents from high-income countries stated that they had access to such services, compared to 33% of respondents from middle-income and 20% from low-income countries. It is clear that very few disability support services exist beyond those provided through NGO-organised community-based programmes. Confirming the findings from the literature, WFDB members highlighted the severe isolation that most persons with deafblindness experience. A lack of accessibility, limited employment opportunities and an accumulation of barriers severely restrict the participation of persons with deafblindness.Each individual follows a different pathway, and this is often dependent of whether deafblindness is pre- or post-lingual, and whether it is acquired at a younger or older age. In all cases, however, a lack of adequate support for a person and his or her family, the cost of assistive devices, the lack of interpreter-guide services, and the lack of rehabilitation services significantly restricts social participation and increases isolation. WFDB members also highlighted the issues of stereotyping and a lack of knowledge amongst family members and friends, which caused isolation within family and friendship groups. Poor communication and family support can lead to issues such as violence, neglect and abuse, and, in extreme cases, persons with deafblindness may be locked away in their homes or medicated so that they sleep all day. Families may also be over protective and prevent individuals from taking risks and participating in the community. Isolation and a lack of independent living skills can result in severe anxiety amongst family members, particularly older parents who fear what will happen to their adult children after they pass away.Due to gender-based discrimination, each of these elements is magnified for women with deafblindness, who are more exposed to abuse and sexual violence. The very few people who master communication techniques in the environment of a person with deafblindness imply that connections are usually formed through an intermediary, such as an interpreter-guide. Awareness needs to be raised so that people, particularly community service providers, are aware of even the basic communication requirements. Typically, when persons with deafblindness retain some residual hearing and sight, people do not communicate effectively.A lack of support for interpreter-guide services is a critical barrier across a range of countries and situations. As outlined in this report, few countries provide adequate, high quality services so that persons with deafblindness can gain a meaningful education, work and social participation. People often have to choose when to use their allocated hours of granted support and sacrifice entire aspects of their life. More positively, WFDB members highlighted the fact that the growth of social media and accessible technology have created a raft of new opportunities through which they can interact with the world and other persons with deafblindness. This should be a major motivation for governments to ensure the accessibility of information communication technology. Organisations of persons with deafblindness play a critical role in reaching out, stimulating and catalysing social activities that include families and communities. Unfortunately, as previously discussed, many people and their families do not benefit from the necessary support from authorities. RecommendationsProvide early intervention and counselling services for families of children with deafblindness.Implement community-based intervention programmes to facilitate the social participation and inclusion of persons with deafblindness. Ensure the adequate provision of interpreter-guides.In our own words: Carlos and Sofia (Brazil)229616023495000“We are a couple of two deafblind persons who have Usher syndrome. We've been married for 12 years, living in Sao Paulo, Brazil. I (Sofia) use a hearing aid that helps me recognise sounds and noises. Carlos Jorge is totally deafblind.“In the first building we lived in, other residents didn’t know how to communicate with us. Carlos uses tactile signing. I use Tadoma and tactile signing. “When we fell in love, Carlos’s family in Rio de Janeiro city were worried and scared because they considered that it would be very difficult for two persons with deafblindness to live together. My teacher explained to them that couples can live independently together and then they accepted.“My family was also worried and wanted me to forget that I was in love. A teacher in Sao Paulo convinced them otherwise. I went to Rio de Janeiro and met the family and they were more relaxed with the idea.“We had a lot of support from friends to book the church, talk to the priest and explain why we needed to be with interpreter-guides during the ceremony.“To become more independent and have autonomy, we had training and adapted the home appliances and devices so they were more accessible for us, we know how to cook, clean, etc. “We have the support of the doorman, neighbourhood, friends and relatives that bring us to the church, the supermarket, the bank and we take a known taxi to go to work. If there are conferences or government meetings, we use the government transportation service for persons with disabilities. When we need to go to the doctor or have a medical test, we go with an interpreter-guide.“One of the most important things when we got married was getting a little puppy. She found out that we were deafblind and helped us to notice noises such as the phone ringing, someone knocking on the door or ringing the doorbell. “We knew it wasn’t easy to live by ourselves, but we needed to adapt ourselves, especially in urgent and dangerous situations.”The long read: Being a woman and a mother with deafblindness Camila Indalecio, BrazilIntroductionThe history of women is marked by struggle and challenges, as we fight for equality and for opportunities within society. Women are often excluded and discriminated against simply because of our gender, and we often have to fight to overcome assumptions and guarantee gender equality. Even today, women across the world face many obstacles to equality, including racial discrimination, violence, poverty and – for those women with disabilities – additional discrimination because we are different. The history of women, however, is defined by the history of women without disabilities. Women with disabilities are, therefore, a minority within a minority. Our stories of struggle and overcoming barriers are either forgotten or unrecognised.Women with deafblindness also suffer specific discrimination within the disability movement. People with other disabilities perceive us as being incapable of participating in public policymaking, having a family, or gaining employment. Because of the different ways in which we communicate, we are rarely given any opportunities, and few people with deafblindness are able to fight for recognition or the right to equity. We, women with deafblindness, face many obstacles simply because we are women. We are submitted and exposed to various difficulties and challenges. Domestic and sexual violence are often hidden, even by the family. Many women with deafblindness suffer silently, day after day, without anyone to defend or protect them. Many women do not have access to information about healthcare or education. To these women, the universe is a silent, dark world. However, a number of women with deafblindness do lead productive lives within society. They fight both as women and as mothers, actively advocating for public policies to guarantee their rights, as well as ensuring family protection. This struggle to achieve recognition in society is experienced by each and every person with deafblindness.Being a woman with deafblindnessI am a woman with acquired deafblindness and Usher syndrome. I found out that I was becoming deafblind when I was 13 years old. When I was 11 I started to lose my hearing and, when I was 23, I lost my sight. Knowing that I would become deafblind when I was 13 did not affect me that much. I was a teenager who was worried about enjoying life to the fullest. My mother, whom I greatly admire, never hid the fact that I would lose both my sight and my hearing. My older sister was already living with deafblindness.During my time at school, however, I was ashamed to accept my deafness, to use hearing aids, and feared that my peers would not accept me. To interact and follow the classes, I learned to lipread. In the second year of high school, I faced the first situation of discrimination in the classroom. The teacher read a text aloud for us to write down. I couldn’t lipread what she said because her head was down while walking around the room. I asked her to speak in front of me, so that I could lipread what she was saying. She replied, "It’s none of my business. If you're deaf, it's not my problem. This is not a school for the deaf." The whole room laughed and made jokes about me. I cried and felt full of shame and begged my mother to move me to another school. I finished high school at an inclusive school where many people with physical disabilities were studying. Unfortunately, I was unable to attend college because I could not get a job to pay for my studies. That's when I became my sister's interpreter-guide. I used to take her to work, to events and leisure activities, and I interpreted newspapers, books, TV and conversations with other family members at home. I began my preparation to live, in the future, as a person with deafblindness. Having seen the routine and barriers faced by my sister in terms of accessibility, I began to imagine what my life as a person with deafblindness would be like. However, wearing their shoes was something totally different. Interpreter-guides strive to convey as much information as possible to the person with deafblindness, to help him or her to interact. Sometimes, however, they may become impatient. This happens a lot with some interpreter-guides, as situations arise where they get frustrated, or think that certain information doesn’t need to be passed on to the person with deafblindness. To have worked as an interpreter-guide was of great value to me; it prepared me to understand that not everything can be transmitted, even if the interpreter-guide is trying their best best. Today, I realise how much I failed my sister. When I became deafblind, I thought that I was prepared to accept the difficulties and challenges that came with it, due to my experiences and interactions with my sister, other persons with deafblindness and my work and learning as an interpreter-guide. Despite being part of my sister’s experience, I was not prepared psychologically, particularly as I had a much greater challenge ahead of me: the challenge of being a ‘deafblind mother’. The despair and sense of incapacity took over me and everything I had learned from persons with deafblindness and the professionals vanished from my mind, leaving everything in the dark.Although my family always supported me, it took me a while to come to terms with it all. It was difficult to accept. I started thinking, ‘What now? How am I going to help my deafblind sister and other persons with deafblindness the way I used to do? How will I raise my child and help him with his school work, his daily activities?’ This was my worst fear and nightmare: how to fully participate in my son's life and whether he would accept me as a mother with deafblindness. Those were just some of the questions I asked myself during this acceptance process. Many mothers with deafblindness face these challenges, but many of them fear sharing the difficulties they are coping with, afraid of showing themselves as weak. As a result, they keep the pain, the frustration and the despair to themselves.Being a mother with deafblindness One of the challenges of being a mother with deafblindness is overprotection from your family. Many people believe that a mother with deafblindness is unable to perform or participate in certain tasks with her children, making her feel incapable or guilty about a situation that is, in truth, socially invented. The mother may end up angry with herself for being deafblind, and she may start to believe that she isn’t able to fully participate in the life of her child like other parents. A family’s attitude can greatly affect the bond between mother and child, and the child may relate to and respect the other family members more than the mother herself. After undergoing a process of acceptance, my family helped me to interact with my son, encouraging him to be close to me, making him aware of my disability and trying to ensure we had a life like any other family.My son was three years old when I became deafblind. I could see very little at that time. There were still many discoveries, such as preparing for him to go to school. I worried a lot. That's when we started adapting games so that I could play soccer with him, I could follow his drawings. How did we do that? While he was drawing, he would tell me what he was doing. We started playing soccer with our hands, sitting on the ground. We used to look for toys that I could feel to play with him. I also wanted to teach my son how to explain different activities to me. For example, while watching children's music videos, he taught me the dance steps and the lyrics of the song.My other sister, Andreia, who later became both my sister and my interpreter-guide, helped me to come up with ideas and taught my son to guide me, or to let me know when he needed something. This phase was a bit easier. The difficulties came later: school and the times when he got ill.To enrol my son in school, I had to go with my mother. The school principals did not allow me to enrol because I was deafblind. They thought I was incapable of making decisions about my son. It upset me a lot and my mother felt that she should protect me from situations where I might feel embarrassed or angry. I have always had a strong temperament, and have always confronted my mother when she tries to protect me from situations involving my son.At pre-school, my child had learning difficulties, and struggled to focus on activities. The teacher and the principal called in my mother to discuss my son. I went along, even though my mother told me not to. The teacher said that my son had not developed because I was deafblind. That, to me, was a huge shock. A slap in the face. I was furious. I pointed my finger at the teacher's face and said, “My son doesn’t have problems with his activities just because I'm deafblind. Children of parents without disabilities go through the same situation and I will prove to you that it is not because of my disability, and that I am fully capable of helping my child to thrive at school!”My mother was initially ashamed, but eventually she realised that I was right to speak up. Because I was taking part in rehabilitation at Grupo Brasil and at the ABRASC, I was able to seek guidance from teachers who work with children with deafblindness. One teacher, Dalva, helped me a lot, and taught me how to use modeling clay so that my son could improve his hand-eye coordination.Writing was more intuitive. As I have a tattoo, my son liked to pretend that he was tattooing my foot. He then began to draw on my feet and legs, where I have more sensitivity. This gave me an idea and I began to help him write in this way: he drew and wrote, and I corrected. Using this method, he started to develop in his school activities.Other difficult situations at school included the presentations and parties. My son's first performance is the last image I have of him. It was a dance performance. I've never felt so much pain when looking forward to seeing something in all my life. The desire to watch my son dance was immense. Although my family was interpreting everything – the clothing, the lyrics of the song, how he was dancing – I could only see the flashes of the cameras. I cried so much and I had to try to calm myself down. When the dance ended, the teacher encouraged the children to meet their parents. Arthur, my son, saw me crying and asked why. I lied. I said that I was thrilled to see him dance. I was surprised by his response. Despite being only three years old, he said, “Mom, I know you do not see anymore, but look, I danced very well. I fell, but I stood up quickly!” At this point, I realised that he was becoming aware of my deafblindness. It was clear that the education my family and I had provided him was starting to show results. He understood me and he was close to me.At another school, my son was bullied for being overweight and for being the son of a woman with disabilities. Once again, the teachers and principals tried to keep me away. They did not want me to participate in his activities and I was again told that he was not developing because I was deafblind. This time, however, I was prepared.People aren’t used to seeing a person with deafblindness playing an active role in their children's lives. This role is usually assumed by another family member. There are still few people who understand the different forms of communication, such as the use of tadoma. When I took my son to school with my sister, and she talked to me, other mothers and fathers would look at me, frightened, suspicious, thinking that I was a lesbian. They started separating their children from mine. My son’s classmates made sick jokes and isolated him, because of their parents.Again, I faced up to the school principals, the teachers, and even the other parents. My mother wanted to protect me from what was happening to my son at school, and tried to solve the issues herself. But I confronted her, explaining that I had the right to know what was going on, whether good or bad.One day, a group of mothers were whispering about me, and about the fact that I was touching my sister's face. She passed me this information and so I asked her to take me to the group. I explained how I communicate and ended up saying that, if I were a lesbian, they should respect me. In doing so, I gained respect, and they started to see me in a different way. To those who called me a ‘pity person’ or who said I was sick, I replied that I have no illness, that I am a person with a disability. When you take away the ‘Dis’ the word that remains is ‘ability’.The role played by the family of a mother with deafblindness is very important. However, the mother herself has to have the courage and desire to face the challenges, and to prevent her family from becoming overprotective. If the family does not support the mother with deafblindness to interact with her own child, enabling them to feel close to each other, how can that bond be strengthened? And what will happen in the future? Sometimes my son rides his bicycle on the street. I sit while other parents accompany their children. My mind is not quiet and every car noise or child's scream terrifies me. I can still communicate and ask for help from someone, though. What about the mothers with deafblindness who can only communicate with tactile Libras or other forms of communication that nobody knows? When I have the opportunity to meet other mothers with deafblindness, I try to share my experiences, teaching them how to participate in their children's school activities.Family support is critical, as is participation in the development of policies, which will ultimately help to break down the barriers. However, reconciling the fact that I am a woman with deafblindness, a mother and a militant, is difficult. A lot of my time is spent on mobility and communicating. I also need time for translation and interpretation, and require the support of professionals, such as interpreter-guides. As a result, in Brazil today, few women with deafblindness have the opportunity to play an active role in the development of public policies.I would like to finish by saying how grateful I am to my mother. Although she sometimes tries to protect me from difficult situations – and this is motherly, I know how it is – she has always given me the support I need. She gives me strength to not give up fighting and has never made me feel incapable. She has always encouraged my sister and I to prove that we are capable. My whole family, my brothers, nephews, nieces and brothers-in-law, are the same. I am grateful to all of those who give persons with deafblindness their full support and encouragement.Conclusion and recommendationsCombining the largest population-based analysis of persons with deafblindness conducted to date (disaggregation of 22 population-based surveys from low, middle and high-income countries), an academic literature review, surveys conducted amongst members and partners of WFDB and Sense International, and consultation with more than 75 women and men with deafblindness who took part in the Helen Keller World Conference in June 2018, this initial global report examines whether the needs of persons with deafblindness, as recognised in the Convention on the Rights of Persons with Disabilities (CRPD), are being met by governments across the world.This report will be followed by several reports up to 2030 to monitor the progress being made to realise the rights of persons with deafblindness according to both the CRPD and Sustainable Development Goals (SDGs).Despite a number of impressive achievements and the tireless advocacy work undertaken by organisations of persons with disabilities and their allies, the report finds that, overall, the issues faced by persons with deafblindness have largely been ignored. As a result, people with deafblindness are being ‘left behind’, contrary to the fundamental principle that underpins the SDGs.Globally, a vicious circle exists, whereby a lack of awareness and a lack of recognition of persons with deafblindness as a distinct disability group have led to invisibility and consequently a failure of governments to recognise inclusion requirements. Due to the specific implications of their disability, persons with deafblindness face additional barriers and require specific support, in particular interpreter-guide services and tailored rehabilitation services, among others. As these services are only available in a few countries, persons with deafblindness benefit little from development efforts, including those aimed at implementing the CRPD. Key findingsPrevious estimates suggest that around 0.2% of the world’s population are living with deafblindness. Analysis of prevalence data in the report found that this figures ignores a vast number of people with milder forms of deafblindness who experience barriers to participation and discrimination. As such, 2% is a more accurate figure, reflecting the diversity of persons with deafblindness. Within the population of persons with deafblindness:While deafblindness is more common among older age groups, deafblindness among children and young adults has a more pronounced impact on daily living, for example in terms of barriers to education, employment and social participation, and a higher risk of poverty. They are ten times less likely to be employed than non-disabled people, and 30% less likely to be employed than persons with other types of disabilities.Children with deafblindness are 17 times less likely to be in school than non-disabled children, and twice less likely to be in school compared to children with other types of disabilities.Families and households that include persons with deafblindness are more likely to be in the bottom 40% in terms of socio-economic status compared to households that include no members with disabilities and households with people who have other disabilities. Women with deafblindness experience increased restrictions in terms of participating in a wide range of activities. In addition:Between 20% and 75% of persons with deafblindness have additional impairments.There is a high prevalence of depression among persons with deafblindness, but low access to mental health services. Children with deafblindness are less likely to live with both parents.Persons with deafblindness are less likely to be married. Persons with deafblindness reported a low quality of life and restrictions in participating across a wide-range of activities. Persons with deafblindness aged over 50 are twice as likely to be socially isolated compared to those without a combined sight and hearing rmation provided by WFDB members and Sense International teams and partners suggest an inadequate policy response from governments:There is an overall lack of awareness and recognition of persons with deafblindness as a distinct disability group. It is often wrongly assumed that people only require at best a combination of the services that exist either for blind or deaf people. This, however, ignores the specific barriers and communication requirements of each person with deafblindness.While the situation is exacerbated in lower-income countries, few countries have developed effective publicly funded support services for persons with deafblindness, especially interpreter-guide services. A lack of support has a negative impact on a person’s social and economic situation, their political participation, and contributes to a high incidence of isolation. Employment policies and services do not adequately support persons with deafblindness.Education provision is generally inadequate, with an overreliance on special education settings and little attention to children with deafblindness specific requirements in inclusive education policies and processes as well.Whilst access to health is better for adults with deafblindness, with the distinct exception of sexual and reproductive health services, it was noted that communication barriers and the negative attitudes of healthcare staff affect the care that people receive. In many countries, healthcare staff do not have the requisite knowledge or training on the causes of deafblindness or the specific communication requirements of individuals.Few countries have developed adequate early detection and intervention services for children with deafblindness, which impacts on their development and family relationships.There are large discrepancies between high and low-income countries in terms of access to social protection. In most countries, existing support does not cover the extra cost of disability (this cost was estimated to be the highest among persons with disabilities in South Africa). Case studies provide insights into innovative practices in health, education, employment and personal experiences, and demonstrate the pathways required to ensure the full and effective participation of persons with deafblindness.RecommendationsThe evidence contained in the report confirms that persons with deafblindness are left behind in terms of disability inclusion and development efforts. In addition to the common demands of the disability movement with regards to accessibility, non-discrimination, participation and inclusion, WFDB members have identified the following recommendations to ensure that persons with deafblindness are able to contribute to and benefit from ongoing and future efforts to achieve the SDGs and implement the CRPD:Pre-conditions for inclusionUniversal and national recognition of deafblindness as a distinct disability in law and practice. Development, in consultation with persons with deafblindness and their organisations, of required support and deafblind interpretation services, in particular interpreter-guides, and adequate public funding to ensure support in education, work and community life.Ensure that organisations of persons with deafblindness are considered as a distinct disability group and are included as such in all consultation with persons with disabilities.Involve persons with deafblindness and their organisations in awareness raising and inclusion-related programmes, serving as role models, mentors and peer support.Adopt, in consultation with persons with deafblindness and their organisations, a consistent definition and measurement of deafblindness, and collect, disaggregate and analyse data, to assess and monitor situation of persons with deafblindness, including through relevant analyses of national datasets using the Washington Group Short Set questions or other methods.Conduct additional research on the issues facing persons with deafblindness, including health status and access to healthcare, social participation and wellbeing, quality of work and education, causes, and age of onset. Undertake impact evaluations of interventions designed to improve inclusion.Social protection Disability determination and eligibility processes should consider persons with deafblindness as a distinct disability group.Disability schemes should take into consideration the significant extra cost of deafblindness, including assistive technology, personal assistance and interpreter-guide services.EducationEnsure that the requirements of persons with deafblindness are taken into account in inclusive education laws, policies and programmes, and efforts are made to adapt curricula, train teachers and provide support to students.Ensure the availability of resource centres that support mainstream schools, children with deafblindness and their families.Ensure the adequate provision of interpreter-guides.Health Provide adequate training to healthcare staff both on the causes of deafblindness and the specific communication requirements of persons with deafblindness.Ensure access to adequate sexual and reproductive health services, with an emphasis on women and girls with deafblindness.Ensure the provision of adequate early detection and intervention services, in partnership with education providers.Ensure the adequate provision of interpreter-guides.Work and employmentEnsure that persons with deafblindness are adequately included in employment-related laws, policies and programmes. Ensure the adequate provision of interpreter-guides for work and employment.Political participationEnsure that the right to vote is granted to all persons with deafblindness. Take into consideration the accessibility requirements of persons with deafblindness with regards to election campaigns, voting materials and polling stations. Support the engagement of persons with deafblindness in political and public life. Support organisations of persons with deafblindness and involve them as a distinct disability group in all consultations with disability movements.Social participationProvide early intervention and counselling services for families of children with deafblindness.Implement community-based intervention programmes to facilitate the social participation and inclusion of persons with deafblindness. Ensure the adequate provision of interpreter-guides.As this report concludes, persons with deafblindness are still left behind in all countries of the world. The initial steps to amend this and bridge the gaps, as this report shows, are:To establish a universal acknowledgement and recognition of deafblindness as a unique and distinct disability, with its own specific challenges, barriers, support and inclusion requirements.Establish publicly funded deafblind interpretation services, in particular interpreter-guides.Provide the necessary funding for further research and strengthening of the advocacy work, including funding of the tools and technical support needed.Fulfilling these steps will contribute to lifting Women and men, girls and boys with deafblindness to a position where they may be able to engage, advocate and contribute on more equal terms paving the way towards full and effective participation and inclusion.For more information on the global report on deafblindness please visit: For more information on the World Federation of the Deafblind please visit: wfdb.euFor more information on Sense International please visit: ADDIN EN.REFLIST 1.World Health Organization & World Bank, World report on disability. 2011: World Health Organization.2.Groce, N. and M. Kett, The Disability and Development Gap, in Leonard Cheshire Working Paper Series. 2013, Leonard Cheshire Disability and Inclusive Development Centre: London.3.The Deafblind Nordic Cooperation Committee. The Nordic definition of deafblindness. n.d. [cited 2018 June 2]; Available from: English.pdf.4.Dammeyer, J., Characteristics of a Danish population of adults with acquired deafblindness receiving rehabilitation services. British Journal of Visual Impairment, 2013. 31(3): p. 189-197.5.Klaver, C.C., et al., Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study. Archives of ophthalmology, 1998. 116(5): p. 653-658.6.Wolsey, J.-L.A., Perspectives and Experiences of DeafBlind College Students. The Qualitative Report, 2017. 22(8): p. 2066.7.Simcock, P., One of society's most vulnerable groups? A systematically conducted literature review exploring the vulnerability of deafblind people. Health & social care in the community, 2017. 25(3): p. 813-839.8.World Federation of the Deafblind. Deafblind Interpretation. 2018 [cited 2018 June 2]; Available from: , P., Ageing with a unique impairment: a systematically conducted review of older deafblind people's experiences. Ageing & Society, 2017. 37(8): p. 1703-1742.10.Dammeyer, J., Deafblindness: a review of the literature. Scandinavian journal of public health, 2014. 42(7): p. 554-562.11.Schneider, J.M., et al., Dual sensory impairment in older age. Journal of Aging and Health, 2011. 23(8): p. 1309-1324.12.Saunders, G.H. and K.V. Echt, An overview of dual sensory impairment in older adults: perspectives for rehabilitation. Trends in amplification, 2007. 11(4): p. 243-258.13.Chia, E.-M., et al., Association between vision and hearing impairments and their combined effects on quality of life. Archives of Ophthalmology, 2006. 124(10): p. 1465-1470.14.Harada, S., et al., Gender difference in the relationships between vision and hearing impairments and negative well-being. Preventive medicine, 2008. 47(4): p. 433-437.15.Schneider, J., et al., Prevalence and 5-year incidence of dual sensory impairment in an older Australian population. Annals of epidemiology, 2012. 22(4): p. 295-301.16.Caban, A.J., et al., Prevalence of concurrent hearing and visual impairment in US adults: The National Health Interview Survey, 1997–2002. American Journal of Public Health, 2005. 95(11): p. 1940-1942.17.Kasthuri, A., Visual and hearing impairment among rural elderly of south India: A community‐based study. Geriatrics & gerontology international, 2012. 12(1): p. 116-122.18.Viljanen, A., et al., Dual sensory loss and social participation in older Europeans. European Journal of Ageing, 2014. 11(2): p. 155-167.19.Brennan, M., Impairment of both vision and hearing among older adults: Prevalence and impact on quality of life. Generations, 2003. 27(1): p. 52-56.20.Cmar, J.L., M.C. McDonnall, and K.M. Markoski, In-School Predictors of Postschool Employment for Youth Who Are Deaf-Blind. Career Development and Transition for Exceptional Individuals, 2017: p. 2165143417736057.21.International Labour Organisation, Women and Men in the Informal Economy: A Statistical Picture. 2002, International Labour Office: Geneva.22.Bruce, S., K. Ferrell, and J.L. Luckner, Guidelines for the Administration of Educational Programs for Students Who Are Deaf/Hard of Hearing, Visually Impaired, or Deafblind. Journal of the American Academy of Special Education Professionals, 2016. 47: p. 59.23.Nelson, C. and S.M. Bruce, Critical Issues in the Lives of Children and Youth Who Are Deafblind. American annals of the deaf, 2016. 161(4): p. 406-411.24.National Centre on Deaf-Blindness, The 2013 National Child Count of Children and Youth who are Deaf-Blind. 2014.25.Wittich, W., D.H. Watanabe, and J.P. Gagne, Sensory and demographic characteristics of deafblindness rehabilitation clients in Montreal, Canada. Ophthalmic Physiol Opt, 2012. 32(3): p. 242-51.26.Purvis, B., et al., Early Identificationand Referral of Infants Who Are Deaf-Blind. 2014, National Center on Deaf-Blindness.27.Crews, J.E. and V.A. Campbell, Vision impairment and hearing loss among community-dwelling older Americans: implications for health and functioning. American journal of public health, 2004. 94(5): p. 823-829.28.McDonnall, M.C., et al., Needs and Challenges of Seniors with Combined Hearing and Vision Loss. Journal of Visual Impairment & Blindness (Online), 2016. 110(6): p. 399.29.Laforge, R.G., W.D. Spector, and J. Sternberg, The relationship of vision and hearing impairment to one-year mortality and functional decline. Journal of Aging and Health, 1992. 4(1): p. 126-148.30.Lam, B.L., et al., Concurrent visual and hearing impairment and risk of mortality: the National Health Interview Survey. Archives of ophthalmology, 2006. 124(1): p. 95-101.31.Liljas, A., et al., OP07 Sensory impairments and mortality in older british community-dwelling men: a 10-year follow-up study. 2015, BMJ Publishing Group Ltd.32.Guthrie, D.M., et al., The health and well-being of older adults with Dual Sensory Impairment (DSI) in four countries. PloS one, 2016. 11(5): p. e0155073.33.Bodsworth, S.M., et al., Deafblindness and mental health: Psychological distress and unmet need among adults with dual sensory impairment. British Journal of Visual Impairment, 2011. 29(1): p. 6-26.34.Chou, K.L. and I. Chi, Combined effect of vision and hearing impairment on depression in elderly Chinese. International journal of geriatric psychiatry, 2004. 19(9): p. 825-832.35.Capella‐McDonnall, M.E., The effects of single and dual sensory loss on symptoms of depression in the elderly. International journal of geriatric psychiatry, 2005. 20(9): p. 855-861.36.Lupsakko, T., et al., Combined hearing and visual impairment and depression in a population aged 75 years and older. International journal of geriatric psychiatry, 2002. 17(9): p. 808-813.37.Heine, C. and C.J. Browning, Mental health and dual sensory loss in older adults: a systematic review. Frontiers in aging neuroscience, 2014. 6: p. 83.38.Cosh, S., et al., The association amongst visual, hearing, and dual sensory loss with depression and anxiety over 6 years: The Troms? Study. International Journal of Geriatric Psychiatry, 2017.39.Davidson, J.G. and D.M. Guthrie, Older adults with a combination of vision and hearing impairment experience higher rates of cognitive impairment, functional dependence, and worse outcomes across a set of quality indicators. Journal of aging and health, 2017: p. 0898264317723407.40.Wiley, S., et al., Outcomes for children with deaf-blindness with cochlear implants: a multisite observational study. Otology & Neurotology, 2013. 34(3): p. 507-515.41.Tiwana, R., S.M. Benbow, and P. Kingston, Late life acquired dual-sensory impairment: A systematic review of its impact on everyday competence. British Journal of Visual Impairment, 2016. 34(3): p. 203-213.42.Brennan, M., Y.-p. Su, and A. Horowitz, Longitudinal associations between dual sensory impairment and everyday competence among older adults. Journal of rehabilitation research and development, 2006. 43(6): p. 777.43.Moller, C., Deafblindness: living with sensory deprivation. The Lancet, 2003. 362: p. s46-s47.44.Lehane, C.M., et al., Sexuality and well-being among couples living with acquired deafblindness. Sexuality and Disability, 2017. 35(2): p. 135-146.45.Lehane, C.M., et al., A relationship-focused investigation of spousal psychological adjustment to dual-sensory loss. Aging & mental health, 2016: p. 1-8.Annex 1Methodological note on the data Challenges in using census data 84455987425Washington Group Short Set of questions for the censusPreamble: “The next questions ask about difficulties you may have in doing certain activities because of a health condition.”Do you have difficulty seeing even if wearing glasses? Do you have difficulty hearing even if using a hearing aid? Do you have difficulty walking or climbing steps? Do you have difficulty remembering or concentrating? Do you have difficulty (with self-care, such as) washing all over or dressing? Do you have difficulty communicating (for example, understanding or being understood)? Response categories: 1) No difficulty 2) Some difficulty 3) A lot of difficulty 4) Cannot do at all(Source: )00Washington Group Short Set of questions for the censusPreamble: “The next questions ask about difficulties you may have in doing certain activities because of a health condition.”Do you have difficulty seeing even if wearing glasses? Do you have difficulty hearing even if using a hearing aid? Do you have difficulty walking or climbing steps? Do you have difficulty remembering or concentrating? Do you have difficulty (with self-care, such as) washing all over or dressing? Do you have difficulty communicating (for example, understanding or being understood)? Response categories: 1) No difficulty 2) Some difficulty 3) A lot of difficulty 4) Cannot do at all(Source: )A strong preference for surveys using the Washington Group Short Set was included when assessing which datasets to include in the quantitative data analysis. The Washington Group Short Set (see the box below) was designed by the Washington Group on Disability Statistics, and has been endorsed by the United Nations Statistical Division for the 2020 round of censuses as a minimum for monitoring inclusion under the UNCRPD and the SDA PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbHRtYW48L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS

ZWNOdW0+MTU4PC9SZWNOdW0+PERpc3BsYXlUZXh0Pls0Mi00NF08L0Rpc3BsYXlUZXh0PjxyZWNv

cmQ+PHJlYy1udW1iZXI+MTU4PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVO

IiBkYi1pZD0id3o1ZWFmNWEwc3QyczZlMnBlYzU1ZnMwejlkdmZ0d3M1cHJlIiB0aW1lc3RhbXA9

IjE1MjgyOTg5NjQiPjE1ODwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3Vy

bmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+

QWx0bWFuLCBCLk0uPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRp

dGxlPkludGVybmF0aW9uYWwgTWVhc3VyZW1lbnQgb2YgRGlzYWJpbGl0eTogUHVycG9zZSwgTWVh

c3VyZSBhbmQgQXBwbGljYXRpb24uIFRoZSBXb3JrIG9mIHRoZSBXYXNoaW5ndG9uIEdyb3VwPC90

aXRsZT48c2Vjb25kYXJ5LXRpdGxlPlNvY2lhbCBJbmRpY2F0b3JzIFJlc2VhcmNoIFNlcmllczwv

c2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPlNvY2lhbCBJ

bmRpY2F0b3JzIFJlc2VhcmNoIFNlcmllczwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHZvbHVt

ZT42MTwvdm9sdW1lPjxkYXRlcz48eWVhcj4yMDE2PC95ZWFyPjwvZGF0ZXM+PHVybHM+PC91cmxz

PjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPlNlY3JldGFyaWF0IHRvIHRoZSBDb252ZW50

aW9uIG9uIHRoZSBSaWdodHMgb2YgUGVyc29ucyB3aXRoIERpc2FiaWxpdGllczwvQXV0aG9yPjxZ

ZWFyPjIwMTQ8L1llYXI+PFJlY051bT4xNjA8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2

MDwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9Ind6NWVhZjVh

MHN0MnM2ZTJwZWM1NWZzMHo5ZHZmdHdzNXByZSIgdGltZXN0YW1wPSIxNTI4Mjk5MDU1Ij4xNjA8

L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iUmVwb3J0Ij4yNzwvcmVmLXR5cGU+

PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPlNlY3JldGFyaWF0IHRvIHRoZSBDb252ZW50

aW9uIG9uIHRoZSBSaWdodHMgb2YgUGVyc29ucyB3aXRoIERpc2FiaWxpdGllcyw8L2F1dGhvcj48

L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PHRpdGxlcz48dGl0bGU+RmluYWwgUmVwb3J0IG9uIFVu

aXRlZCBOYXRpb25zIEV4cGVydCBHcm91cCBNZWV0aW5nIG9uIERpc2FiaWxpdHkgRGF0YSBhbmQg

U3RhdGlzdGljcywgTW9uaXRvcmluZyBhbmQgRXZhbHVhdGlvbjogVGhlIFdheSBGb3J3YXJkIC0g

YSBEaXNhYmlsaXR5LUluY2x1c2l2ZSBBZ2VuZGEgVG93YXJkcyAyMDE1IGFuZCBCZXlvbmQ8L3Rp

dGxlPjwvdGl0bGVzPjxkYXRlcz48eWVhcj4yMDE0PC95ZWFyPjwvZGF0ZXM+PHB1Yi1sb2NhdGlv

bj5QYXJpczwvcHViLWxvY2F0aW9uPjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+PENpdGU+

PEF1dGhvcj5Vbml0ZWQgTmF0aW9ucyBFY29ub21pYyBhbmQgU29jaWFsIENvdW5jaWw8L0F1dGhv

cj48WWVhcj4yMDE2PC9ZZWFyPjxSZWNOdW0+MTU5PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJl

cj4xNTk8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ3ejVl

YWY1YTBzdDJzNmUycGVjNTVmczB6OWR2ZnR3czVwcmUiIHRpbWVzdGFtcD0iMTUyODI5OTAwMiI+

MTU5PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IlJlcG9ydCI+Mjc8L3JlZi10

eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5Vbml0ZWQgTmF0aW9ucyBFY29ub21p

YyBhbmQgU29jaWFsIENvdW5jaWwsPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0

aXRsZXM+PHRpdGxlPkRpc2FiaWxpdHkgU3RhdGlzdGljcyBSZXBvcnQgb2YgdGhlIFNlY3JldGFy

eS1HZW5lcmFsIGFuZCB0aGUgV2FzaGluZ3RvbiBHcm91cDwvdGl0bGU+PC90aXRsZXM+PGRhdGVz

Pjx5ZWFyPjIwMTY8L3llYXI+PC9kYXRlcz48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjwv

RW5kTm90ZT4A

ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BbHRtYW48L0F1dGhvcj48WWVhcj4yMDE2PC9ZZWFyPjxS

ZWNOdW0+MTU4PC9SZWNOdW0+PERpc3BsYXlUZXh0Pls0Mi00NF08L0Rpc3BsYXlUZXh0PjxyZWNv

cmQ+PHJlYy1udW1iZXI+MTU4PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtleXM+PGtleSBhcHA9IkVO

IiBkYi1pZD0id3o1ZWFmNWEwc3QyczZlMnBlYzU1ZnMwejlkdmZ0d3M1cHJlIiB0aW1lc3RhbXA9

IjE1MjgyOTg5NjQiPjE1ODwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYtdHlwZSBuYW1lPSJKb3Vy

bmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxhdXRob3JzPjxhdXRob3I+

QWx0bWFuLCBCLk0uPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0aXRsZXM+PHRp

dGxlPkludGVybmF0aW9uYWwgTWVhc3VyZW1lbnQgb2YgRGlzYWJpbGl0eTogUHVycG9zZSwgTWVh

c3VyZSBhbmQgQXBwbGljYXRpb24uIFRoZSBXb3JrIG9mIHRoZSBXYXNoaW5ndG9uIEdyb3VwPC90

aXRsZT48c2Vjb25kYXJ5LXRpdGxlPlNvY2lhbCBJbmRpY2F0b3JzIFJlc2VhcmNoIFNlcmllczwv

c2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPlNvY2lhbCBJ

bmRpY2F0b3JzIFJlc2VhcmNoIFNlcmllczwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHZvbHVt

ZT42MTwvdm9sdW1lPjxkYXRlcz48eWVhcj4yMDE2PC95ZWFyPjwvZGF0ZXM+PHVybHM+PC91cmxz

PjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPlNlY3JldGFyaWF0IHRvIHRoZSBDb252ZW50

aW9uIG9uIHRoZSBSaWdodHMgb2YgUGVyc29ucyB3aXRoIERpc2FiaWxpdGllczwvQXV0aG9yPjxZ

ZWFyPjIwMTQ8L1llYXI+PFJlY051bT4xNjA8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjE2

MDwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9Ind6NWVhZjVh

MHN0MnM2ZTJwZWM1NWZzMHo5ZHZmdHdzNXByZSIgdGltZXN0YW1wPSIxNTI4Mjk5MDU1Ij4xNjA8

L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iUmVwb3J0Ij4yNzwvcmVmLXR5cGU+

PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPlNlY3JldGFyaWF0IHRvIHRoZSBDb252ZW50

aW9uIG9uIHRoZSBSaWdodHMgb2YgUGVyc29ucyB3aXRoIERpc2FiaWxpdGllcyw8L2F1dGhvcj48

L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PHRpdGxlcz48dGl0bGU+RmluYWwgUmVwb3J0IG9uIFVu

aXRlZCBOYXRpb25zIEV4cGVydCBHcm91cCBNZWV0aW5nIG9uIERpc2FiaWxpdHkgRGF0YSBhbmQg

U3RhdGlzdGljcywgTW9uaXRvcmluZyBhbmQgRXZhbHVhdGlvbjogVGhlIFdheSBGb3J3YXJkIC0g

YSBEaXNhYmlsaXR5LUluY2x1c2l2ZSBBZ2VuZGEgVG93YXJkcyAyMDE1IGFuZCBCZXlvbmQ8L3Rp

dGxlPjwvdGl0bGVzPjxkYXRlcz48eWVhcj4yMDE0PC95ZWFyPjwvZGF0ZXM+PHB1Yi1sb2NhdGlv

bj5QYXJpczwvcHViLWxvY2F0aW9uPjx1cmxzPjwvdXJscz48L3JlY29yZD48L0NpdGU+PENpdGU+

PEF1dGhvcj5Vbml0ZWQgTmF0aW9ucyBFY29ub21pYyBhbmQgU29jaWFsIENvdW5jaWw8L0F1dGhv

cj48WWVhcj4yMDE2PC9ZZWFyPjxSZWNOdW0+MTU5PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJl

cj4xNTk8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJ3ejVl

YWY1YTBzdDJzNmUycGVjNTVmczB6OWR2ZnR3czVwcmUiIHRpbWVzdGFtcD0iMTUyODI5OTAwMiI+

MTU5PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IlJlcG9ydCI+Mjc8L3JlZi10

eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5Vbml0ZWQgTmF0aW9ucyBFY29ub21p

YyBhbmQgU29jaWFsIENvdW5jaWwsPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJpYnV0b3JzPjx0

aXRsZXM+PHRpdGxlPkRpc2FiaWxpdHkgU3RhdGlzdGljcyBSZXBvcnQgb2YgdGhlIFNlY3JldGFy

eS1HZW5lcmFsIGFuZCB0aGUgV2FzaGluZ3RvbiBHcm91cDwvdGl0bGU+PC90aXRsZXM+PGRhdGVz

Pjx5ZWFyPjIwMTY8L3llYXI+PC9kYXRlcz48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjwv

RW5kTm90ZT4A

ADDIN EN.CITE.DATA [42-44].The questions were designed for ease of use and comparable interpretation across countries and over time. They are useful in identifying persons with deafblindness from population datasets, allowing analyses to be separated by the severity of functional limitation (e.g. the differences in terms of access to work between those reporting ‘a lot’ of difficulty or ‘cannot do’ in both domains, compared to those reporting ‘some’ difficulty). However, it proved difficult to identify sufficiently large datasets that had used the Washington Group Short Set, and so some datasets had to be included that did not use this measure. It is important that this method continues to be integrated into population data collection, and for it to be integrated in its entirety. For example, a number of datasets included questions 1 to 4 of the short set, but excluded the questions on self-care and communication that would have been useful to analyse people with deafblindness. By excluding specific questions and using non-comparable alternatives, the population identified in analyses as having ‘other disabilities’ is also different across datasets, again limiting direct comparability.An additional concern in terms of the use of census data for deafblindness-related analyses is the frequent exclusion of institutional or homeless populations from either sampling or disability-specific modules. As people with disabilities, including people with deafblindness, are likely overrepresented in these groups, approximations of deafblindness may be underestimated. Furthermore, as people with deafblindness often have multiple impairments, visual and hearing loss may not always be reported, particularly when impairments are captured in a ‘check all that apply’ approach, rather than through impairment and/or functional limitation-specific questions. Moreover, questions about individual household members are typically answered by the household head, rather than through self-reporting. Proxy reporting has been linked to the underestimation of disability, which likely applies to deafblindness. Furthermore, census data collection is rarely adapted to alternative communication styles, which means that people with deafblindness are often unable to share their experiences directly. Finally, due to the prevalence of deafblindness being relatively low amongst younger age groups, even some large census datasets do not include sufficient numbers to be able to conduct robust analyses. Indicators in domains such as health and social participation were also lacking. Furthermore, whilst data can provide information on school enrolment and/or attainment and work status, indicators are lacking on the quality of work and education. Going forward, it is important to achieve consensus and the consistent use of a definition and measurement of deafblindness so that future data is comparable over time and location. In addition, focused studies on deafblindness using alternative data collection methods, such as qualitative methods or in-depth deafblindness-specific surveys, can provide complementary information about the lived experience of deafblindness, which is not always captured in large-scale surveys. In combination, these approaches can help to ensure that deafblindness is captured in monitoring and evaluation of both the CRPD and the SDGs.Statistical Appendix 1: Data analysis methodologyData acquisitionThe data used in the quantitative analyses was acquired via the IPUMS-International website () between 2017 and 2018. IPUMS-International is a collaborative project between the University of Minnesota, National Statistical Offices, international data archives, and other international organisations ADDIN EN.CITE <EndNote><Cite><Author>Minnesota Population Center</Author><Year>2018</Year><RecNum>157</RecNum><DisplayText>[45]</DisplayText><record><rec-number>157</rec-number><foreign-keys><key app="EN" db-id="wz5eaf5a0st2s6e2pec55fs0z9dvftws5pre" timestamp="1528297925">157</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Minnesota Population Center,</author></authors></contributors><titles><title>Integrated Public Use Microdata Series, International</title><secondary-title>Version 7.0 [dataset]</secondary-title></titles><dates><year>2018</year></dates><pub-location>Minneapolis, MN</pub-location><publisher>IPUMS</publisher><urls><related-urls><url>;[45]. The project aims to provide an inventory of global census data for secondary data analyses by qualified researchers.Datasets were selected for inclusion based on:Geographic and income level spread.Sufficient sample size to allow analyses disaggregated by deafblindness.An appropriate and broadly comparable measurement of deafblindness, with a strong preference for those using the Washington Group Short Set.Data processingAll of the data was analysed in Stata SE version 15.0.Data analysisPeople with and without deafblindnessSurvey respondents under five years of age were excluded from analyses based on the lack of a validated survey tool for measuring deafblindness in that age group. Survey respondents aged five years and older were categorised into one of three mutually exclusive groups:Persons with deafblindness (‘a lot’ or greater difficulty seeing and hearing; or a binary ‘yes’ response to difficulty seeing or hearing; or a binary ‘yes’ response to being deaf and blind, depending on the survey methodology).Persons with other disabilities (‘a lot’ or greater difficulty in any other functional domain; or a binary ‘yes’ response to having another impairment, depending on the survey methodology).Persons without disabilities (not included within either of the aforementioned categories).Prevalence estimates-64135680085Explaining confidence intervals and odds ratiosAn odds ratio (OR) is a measure of the association between an exposure and an outcome. In this example, OR measures between household poverty (exposure) and whether the person has deafblindness (outcome). The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. An OR of 1 suggests no association between the exposure and outcome. An OR>1 suggests the exposure is associated with a higher chance of the outcome occurring. An OR <1 suggests the exposure is associated with lower odds of the outcome occurring.The 95% confidence interval shows the range of odds ratios that are likely, with 95% probability. If the confidence interval does not include 1, then the odds ratio is statistically significant (as in the example given above). Confidence intervals are also shown around estimates of prevalence, indicating the range within which we can be 95% sure that the true population estimate exists. For example: Odds of deafblindness for a person living in the poorest household group = 250/262 = 0.95. Odds of deafblindness for a person living in the wealthiest household group = 46/26 = 1.77. Odds ratio = 1.77/0.95 = 1.9 – 95% confidence interval 1.1 – 3.1. This means that people living in the poorest households are almost twice as likely to have deafblindness compared to those living in the wealthiest households, and that this result is statistically significant at the 95% confidence interval.00Explaining confidence intervals and odds ratiosAn odds ratio (OR) is a measure of the association between an exposure and an outcome. In this example, OR measures between household poverty (exposure) and whether the person has deafblindness (outcome). The OR represents the odds that an outcome will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. An OR of 1 suggests no association between the exposure and outcome. An OR>1 suggests the exposure is associated with a higher chance of the outcome occurring. An OR <1 suggests the exposure is associated with lower odds of the outcome occurring.The 95% confidence interval shows the range of odds ratios that are likely, with 95% probability. If the confidence interval does not include 1, then the odds ratio is statistically significant (as in the example given above). Confidence intervals are also shown around estimates of prevalence, indicating the range within which we can be 95% sure that the true population estimate exists. For example: Odds of deafblindness for a person living in the poorest household group = 250/262 = 0.95. Odds of deafblindness for a person living in the wealthiest household group = 46/26 = 1.77. Odds ratio = 1.77/0.95 = 1.9 – 95% confidence interval 1.1 – 3.1. This means that people living in the poorest households are almost twice as likely to have deafblindness compared to those living in the wealthiest households, and that this result is statistically significant at the 95% confidence interval.Prevalence estimates were calculated using the ‘SVY’ command to account for clustering and to provide a 95% confidence interval. Estimates were also adjusted using IPUMS-International Sample Weights for individuals. Prevalence estimates were stratified by age group and by gender.Poverty estimatesTo compare the socioeconomic status of participants, a principal component analysis of durable household asset ownership (e.g. cars, internet and mobile phones) and housing characteristics (e.g. flooring material, walls and type of sanitation facilitations) were computed for each country. Principal component scores were then divided into quintiles. Poverty was defined as being in the lowest two quintiles (bottom 40%). ORs were calculated comparing households including people with deafblindness to households including people with other disabilities and households with no disabilities, adjusted for urban and/or rural region, household size and dependency proportion (number of children <15 years and adults 65+ years over the total household size).Poverty estimates were also disaggregated based on whether the person with deafblindness was above or below 50 years of age. In households that included multiple members with deafblindness of differing ages, a household was classified as being under 50 if there was at least one member with deafblindness aged below 50. ORs were calculated by comparing households that included members with deafblindness under 50 to households with members with deafblindness over 50, adjusting for household size and dependency proportion. DemographicsAmongst adults (18+), estimates of several demographic indicators were calculated. Current marital status was assessed in two ways. First, individuals were categorised as: never married, currently married, widowed or divorced/separated. Second, a binary variable was added: currently married/not currently married. ORs were calculated by comparing people with deafblindness to people with other disabilities and people with no disabilities. This was adjusted by age group, gender, urban and/or rural region, and stratified by age group and gender.Presence of biological parents in the household was calculated based on the listed relationships between household members. A child (<18 years) was deemed not to have at least one biological parent present in the household if the household roster did not indicate the presence of that child’s biological mother or father. ORs were calculated comparing children with deafblindness to children with other disabilities and children with no disabilities. These were adjusted by age group, gender and urban and/or rural region.EducationLiteracy was calculated as a binary can/cannot read at any level variable with ORs determined as above. Previous schooling was calculated in the same way (any level of schooling versus no schooling).LivelihoodsLivelihood analyses were restricted to the working age population (aged 15 to 64) and those not currently enrolled in education. A binary variable was created across the datasets on having worked in the past 12 months versus not having worked at all, with stratified and adjusted ORs calculated as above.Activity status amongst participants who reported that they had not undertaken any work in the last 12 months was assessed as ‘unemployed and looking for work’ or ‘inactive. Inactive includes all those who are not considered to be a part of the labour force, for example due to child care, retirement or a perceived inability to work.Detailed data tables Prevalence of deafblindness by age group (%)5-1718-3940-5960-7475+Sudan0.0120.0280.2101.5205.660Mexico0.0120.0130.0750.5903.540Ireland0.0360.0470.1500.4702.910USA0.1100.1400.4701.2005.640Indonesia0.0120.0100.0250.3102.160Ghana0.0710.0880.1800.5401.480Vietnam0.0640.0630.1050.7645.910Uruguay0.0180.0170.0830.3601.740Tanzania0.0090.0080.0360.1701.310South Africa0.1000.0660.2200.7102.930Brazil0.0600.0800.3101.0404.570Poverty (in bottom 40%) of households with deafblindness, other disabilities and no disabilities (%)DeafblindOther disabilityNo disabilityAdj. OR1Adj. OR2Sudan43.45%41.93%40.35%1.01 (0.94-1.08)1.19 (1.11-1.28)*Mexico50.42%43.27%39.22%1.16 (1.13-1.20)*1.13 (1.10-1.17)*Ireland59.40%43.20%33.50%1.65 (1.44-1.90)*2.41 (2.11-2.77)*USA56.02%46.85%37.76%1.38 (1.34-1.43)*2.16 (2.09-2.24)*Indonesia52.07%47.25%39.80%1.11 (1.06-1.16)*1.27 (1.22-1.33)*Ghana55.79%50.70%38.91%1.14 (1.03-1.26)*1.39 (1.25-1.55)*Vietnam46.48%47.21%39.59%0.91 (0.89-0.94)*1.01 (0.99-1.04)Uruguay51.23%46.88%39.10%1.19 (1.01-1.40)*1.57 (1.33-1.84)*Tanzania57.14%50.22%39.50%1.09 (0.97-1.24)1.38 (1.22-1.57)*South Africa49.96%44.10%39.49%1.18 (1.12-1.26)*1.48 (1.40-1.55)*Brazil52.93%47.38%38.66%1.21 (1.17-1.25)*1.67 (1.62-1.72)*1 Compares deafblindness versus other disabilities2 Compares deafblindness to no disabilities*Denotes statistically significant difference at 95% confidence levelWorking status of adults (18+) with deafblindness, other disabilities and no disabilities (%)DeafblindOther disabilityNo disabilityAdj. OR1Adj. OR2Sudan29.65%38.84%45.58%1.32 (1.16-1.5)*2.08 (1.82-2.37)*Mexico39.92%38.85%52.38%0.95 (0.81-1.12)2.48 (2.12-2.91)*Ireland22.90%34.99%70.38%1.75 (1.33-2.32)*7.3 (5.52-9.63)*USA28.73%32.05%75.00%1.14 (1.06-1.22)*7.27 (6.79-7.79)*Indonesia39.92%38.85%52.38%1.95 (1.7-2.24)*23.29 (20.30-26.71)*Ghana69.50%67.82%80.82%0.92 (0.81-1.04)2.16 (1.9-2.45)*Vietnam15.86%36.20%88.94%3.31 (3.05-3.60)*61.05 (56.27-66.25)*Uruguay41.67%26.96%77.37%0.44 (0.25-0.76)*4.81 (2.79-8.27)*Tanzania51.05%60.86%81.44%1.69 (1.31-2.19)*5.34 (4.14-6.90)*South Africa24.10%28.77%46.28%1.20 (1.09-1.32)*2.47 (2.25-2.71)*Brazil39.84%39.86%64.72%0.96 (0.91-1.00)2.50 (2.37-2.63)*1 Compares deafblindness versus other disabilities2 Compares deafblindness to no disabilities*Denotes statistically significant difference at 95% confidence levelWorking status of adults (15-29) with deafblindness, other disabilities and no disabilities (%)DeafblindOther disabilityNo disabilityAdj. OR1Adj. OR2Sudan32.56%33.51%38.03%0.93 (0.6-1.46)1.2 (0.77-1.87)Mexico20.06%28.65%43.32%1.12 (0.75-1.66)3.87 (2.61-5.73)*Ireland31.03%30.71%50.18%1.00 (0.45-2.24)2.29 (1.03-5.1)*USA34.39%33.53%64.47%0.79 (0.64-0.98)*2.73 (2.21-3.38)*Indonesia8.67%19.19%57.98%2.70 (1.82-4.01)*20.90 (14.12-30.92)*Ghana63.37%60.04%70.27%0.88 (0.71-1.09)1.43 (1.16-1.77)*Vietnam12.05%33.73%90.25%4.15 (3.46-4.97)*102.32 (85.72-122.13)*Tanzania47.22%56.49%77.42%1.97 (0.99-3.90)6.19 (3.13-12.24)*South Africa23.57%25.96%38.05%1.05 (0.81-1.35)1.83 (1.42-2.35)*Brazil42.26%37.48%62.16%0.77 (0.66-0.90)*2.19 (1.87-2.57)*Working status of adults (30-49) with deafblindness, other disabilities and no disabilities (%)Sudan37.86%47.53%54.40%1.32 (0.99-1.77)2.24 (1.68-2.98)*Mexico44.81%45.63%61.98%1.12 (0.75-1.66)3.87 (2.61-5.73)*Ireland27.00%40.56%73.30%1.86 (1.17-2.97)*7.51 (4.74-11.93)*USA34.40%35.47%78.88%0.99 (0.88-1.12)7.04 (6.24-7.94)Indonesia17.58%32.26%75.17%2.59 (1.97-3.39)*60.49 (46.29-79.03)*Ghana79.08%74.93%89.13%0.78 (0.64-0.97)*2.34 (1.91-2.88)*Vietnam14.74%39.73%92.57%--Tanzania48.86%62.36%84.45%1.94 (1.34-2.79)*6.41 (4.47-9.20)*South Africa30.42%35.30%54.33%1.19 (1.03-1.38)*2.52 (2.19-2.91)*Brazil48.82%46.22%71.59%0.89 (0.82-0.97)*2.67 (2.46-2.91)*Working status of adults (50-64) with deafblindness, other disabilities and no disabilities (%)Sudan26.34%34.24%52.39%1.07 (0.9-1.29)2.28 (1.91-2.72)*Mexico40.88%38.03%53.52%0.89 (0.73-1.09)2.01 (1.65-2.45)*Ireland18.92%26.22%62.25%1.60 (1.09-2.36)*7.57 (4.73-11.93)*USA25.85%30.44%71.27%1.34 (1.23-1.46)*7.92 (7.27-8.63)*Indonesia18.25%29.46%72.44%1.74 (1.43-2.11)*18.66 (15.44-22.55)*Ghana62.58%64.50%84.06%1.07 (0.87-1.33)3.26 (2.65-4.02)*Vietnam19.24%35.00%76.79%2.39 (2.12-2.70)*19.84 (17.67-22.28)*Tanzania55.97%62.34%84.27%1.24 (0.81-1.89)3.77 (2.48-5.73)*South Africa20.18%24.02%41.52%1.21 (1.06-1.39)*2.55 (2.24-2.90)*Brazil34.32%34.76%53.33%1.06 (0.99-1.13)2.22 (2.08-2.37)*1 Compares deafblindness versus other disabilities2 Compares deafblindness to no disabilities*Denotes statistically significant difference at 95% confidence levelAnnex 2: Included datasetsCountryIncome groupaRegionaYearSample sizeSurvey titleAgencyMeasurement of deafblindnessDatasets included in prevalence estimates onlyBotswanaUpper middleSub-Saharan Africa2011201,7522011 Population and Housing CensusBotswana Central Statistics OfficeDoes any listed persons (from section A or B) have any of the following disabilities: partially sighted, total blindness, partial hearing or deafnessCambodiaLower middleEast Asia and the Pacific20081,340,121General Population Census of Cambodia, 2008Cambodia National Institute of Statistics, Ministry of PlanningIf the person is physically and/or mentally disabled, give the appropriate code number from the list below. Codes: In seeing, In hearingCameroonLower middleSub-Saharan Africa20051,772,359Third General Census of Population and HousingBureau Central des Recensements et des ?tudes de Population, CameroonDoes [the respondent] have any serious disability that limits his/her full participation in life activities (such as mobility, work, social life, etc.? a. sight (Yes/No) b. hearing (Yes/No)ColombiaUpper middleLatin America and the Caribbean20054,117,607General Census 2005 (XVII of Population and Dwelling and VI of Housing).Departmento Administrativo Nacional de Estadística (DANE)Does [the respondent] have permanent limitations for: sight, despite using contact lenses or glasses? (Yes/No); hearing, even with hearing aids? (Yes/No)EcuadorUpper middleLatin America and the Caribbean20101,448,233VII Censo de Población y VI de Vivienda, 2010Instituto Nacional de Estadística y Censos, Ecuador[For all persons who reported having a permanent disability that has lasted for more than one year]. The disability of the respondent is (more than one answer is allowed): Visual (blindness)? Auditory (deafness)?HaitiLow Latin America and the Caribbean2003838,045Recensement General de la Population et de l'HabitatRépublique d'Ha?ti Ministère de l'Economie et des Finances, Institute Ha?tien de Statistique et d'InformatiqueDoes this person have a disability? (Check as many boxes as apply): a. Blind; b. deafIranUpper middleMiddle East and North Africa20111,481,5862011 National Population and Housing CensusStatistical Center of IranDoes any member of the household have at least one of the following??(up to three per member) a. blindness; b. deafnessKenyaLower middleSub-Saharan Africa20093,841,9352009 Kenya Population and Housing CensusKenya National Bureau of StatisticsWhat type of disability does [person] have? (List not more than three) a. visual; b. hearingMalawiLowSub-Saharan Africa20081,343,0782008 Population and Housing CensusMalawi National Statistical OfficeDoes [the respondent] have difficulty or problems in the following? Type of disability: a. Sight b. hearingMozambiqueLowSub-Saharan Africa20072,047,048III Recenseamiento Geral da Popula??o e Habita??o, 2007Mozambique Instituto Nacional de Estatística Does [the person] have any disability? If yes (select): a. blind; b. deafVenezuelaUpper middleLatin America and the Caribbean20012,306,489XIII Censo General de Población y ViviendaVenezuela Instituto Nacional de Estadística (INE), Unidad Técnica censal (UTC)Does [the person] have any disability? If yes (select): a. blind; b. deafDatasets included in full analysesBrazilUpper middleLatin America and the Caribbean20109,693,058XII Recenseamento Geral do Brasil. Censo Demográfico 2010Instituto Brasileiro de Geografia e EstatísticaWashington Group questions for sight and hearing. Deafblindness considered ‘a lot’ of difficulty in both domainsGhanaLower middleSub-Saharan Africa20102,466,2892010 Population and Housing CensusGhana Statistical ServiceDoes [the respondent] have any serious disability that limits his or her full participation in life activities (such as mobility, work, social life, etc.)? Sight (Yes/No); hearing (Yes/No)IndonesiaLower middleEast Asia and the Pacific201022,928,7952010 Population CensusCentral Bureau of StatisticsWashington Group questions for sight and hearing (response options: none, some, total). Deafblindness considered ’total’ difficulty in both domainsIrelandHighEurope and Central Asia2011474,353Census of Population of Ireland, 2011Central Statistics OfficeDo you have any of the following long-lasting conditions or difficulties? Deafness or a serious hearing impairment (Yes/No); Blindness or a serious visual impairment (Yes/No)MexicoUpper middleLatin America and the Caribbean201511,344,365Intercensal Survey 2015Instituto Nacional de Estadística, Geografía e Informática (INEGI)Does [the respondent] have difficulty doing the following activities in his or her daily life: a. Seeing, even when using glasses (Yes/No); b. Hearing, even when using a hearing aid (Yes/No)South AfricaUpper middleSub-Saharan Africa20114,337,697Census 2011Statistics South AfricaWashington Group questions for sight and hearing. Deafblindness considered ‘a lot’ of difficulty in both domainsSudanLowSub-Saharan Africa2008542,7655th Sudan Population and Housing CensusSouthern Sudan Centre for Census, Evaluation and StatisticsDoes [the respondent] have any difficulty in moving, seeing, hearing, speaking or learning? (Mark all that apply) a. difficulty hearing; b. deaf; c. difficulty seeing; d. blindTanzaniaLowSub-Saharan Africa20124,498,0222012 Population and Housing CensusNational Bureau of Statistics, TanzaniaWashington Group questions for sight and hearing. Deafblindness considered ‘a lot’ of difficulty in both domainsUSAHigh North America20103,061,692National Census US Census Bureau, USAIs this person deaf or does he or she have serious difficulty hearing? (Yes/No)?Is this person blind or does he or she have serious difficulty seeing even when wearing glasses? (Yes/No)UruguayHighLatin America and the Caribbean2011328,425General Population Census VIII, Homes IV and Housing VINational Institute of Statistics, UruguayWashington Group questions for sight and hearing. Deafblindness considered ‘much’ difficulty in both domainsVietnamLower middleEast Asia and the Pacific200914,177,5902009 Population and Housing CensusGeneral Statistics Office, VietnamWashington Group questions for sight and hearing. Deafblindness considered ‘very difficult’ in both domainsAcknowledgement and disclaimers The project is coordinated by Rune Jensen and Ximena Serpa under the supervision of Geir Jensen with technical support from Alexandre Cote (IDA-CIP), Bailey Grey and Alison Marshall (Sense International), Morgon Banks and Islay MacTaggart of International Centre for Evidence in Disability (ICED). The WFDB and SI surveys were developed with the support of Akiko Fukuda, WFDB General Secretary from Japan.The team would like to thank all the persons that contributed to the report, in particular the WFDB board members and UN agencies personnel that took part in the September 2017 Geneva technical meeting as well as all the presenters and participants at the Helen Keller World Conference 2018The report was made possible thanks to the overall organisational and technical support of the International Disability Alliance and the Norwegian Association of the Deafblind and the financial support from the UK Department for International Development (DFID) and Norwegian Ministry of Foreign Affairs (NMFA). The information and views set out in this background document are those of the author(s) and do not necessarily reflect the official opinion of the International Disability Alliance, the Norwegian Association of the Deafblind, the International Centre for Evidence in Disability (ICED) at the London School of Hygiene and Tropical Medicine (LSHTM), the UK Department for International Development (DFID) and Norwegian Ministry of Foreign Affairs (NMFA).1016018542000In cooperation with:143979332801900497713035433000331055932512000-29654520320000With the support of: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download