Parul Bakhshi

Disability, vulnerability and citizenship: to what extent is education a protective mechanism for children with disabilities in countries affected by conflict?

Humanitarian crises as a result of conflict are often characterised by failure of the social contract between the state and its citizens. For a variety of reasons, children with disabilities are often particularly vulnerable in time of humanitarian crisis. This paper draws on research undertaken by the authors in a series of countries affected by conflict and looks at how the politics and policies of such countries, and the humanitarian and development agencies working in them, continue to exclude children with disabilities from formal and informal education structures. It will be argued that this exclusion not only impedes progress on inclusive education, but also has wider implications as education programmes are often the conduit through which a number of additional child protection mechanisms are implemented. Children with disabilities who are not in the formal education system are therefore at risk not only of missing out on education opportunities, but are also excluded from critical child survival initiatives, thus increasing their vulnerability.

Mental illness, poverty and stigma in India: a case–control study

Objective To assess the effect of experienced stigma on depth of multidimensional poverty of persons with severe mental illness (PSMI) in Delhi, India, controlling for gender, age and caste. Design Matching case (hospital)–control (population) study. Setting University Hospital (cases) and National Capital Region (controls), India. Participants A case–control study was conducted from November 2011 to June 2012. 647 cases diagnosed with schizophrenia or affective disorders were recruited and 647 individuals of same age, sex and location of residence were matched as controls at a ratio of 1:2:1. Individuals who refused consent or provided incomplete interview were excluded. Main outcome measures Higher risk of poverty due to stigma among PSMI. Results 38.5% of PSMI compared with 22.2% of controls were found poor on six dimensions or more. The difference in multidimensional poverty index was 69% between groups with employment and income of the main contributors. Multidimensional poverty was strongly associated with stigma (OR 2.60, 95% CI 1.27 to 5.31), scheduled castes/scheduled tribes/other backward castes (2.39, 1.39 to 4.08), mental illness (2.07, 1.25 to 3.41) and female gender (1.87, 1.36 to 2.58). A significant interaction between stigma, mental illness and gender or caste indicates female PSMI or PSMI from ‘lower castes’ were more likely to be poor due to stigma than male controls (p<0.001) or controls from other castes (p<0.001). Conclusions Public stigma and multidimensional poverty linked to SMI are pervasive and intertwined. In particular for low caste and women, it is a strong predictor of poverty. Exclusion from employment linked to negative attitudes and lack of income are the highest contributors to multidimensional poverty, increasing the burden for the family. Mental health professionals need to be aware of and address these issues.

Capabilities, Perception of Well-being and Development Effort: Some Evidence from Afghanistan

This paper examines the relationship between capabilities, well-being and the impact of development efforts in Afghanistan. Using data from a nationally representative survey, it is argued that very vulnerable groups maintain a positive perception of well-being by referring to collective values and practices. The data suggest that deprivation of individual basic capabilities does not systematically lead to a low perception of well-being if individuals have access to other capabilities such as love, care and participation in community affairs. Nevertheless, access to basic capabilities remains crucial in order to ensure that social norms and expectations cease to constitute constraints and become factors through which agency and empowerment are enhanced. The results also show the dangers of tackling inequalities by designing policies that target individuals isolated from the group.

Illiteracy among adults with disabilities in the developing world: a review of the literature and a call for action

In the early 1990s, UNESCO estimated that perhaps 97% of the world’s 650 million disabled persons were unable to read or write, leading to significant efforts throughout the developing world to ensure that all children with disabilities attended school through ‘inclusive education’ programs. But what of the vast majority of persons with disabilities who now are adolescents or adults, well beyond the reach of classroom education, or the estimated 90% of disabled children who will ‘age out’ of the system before such inclusive education is available in their communities. In this paper, we review findings from a global literature search on literacy of adults with disability in developing countries which shows that there is currently little in international development, education, health, or disability studies that addresses this issue. On the basis of these findings we argue that while inclusive education efforts for children are important, more attention also needs to be directed to providing literacy skills to illiterate and marginally literate disabled adolescents and adults. A concerted effort to improve access to basic literacy and numeracy skills through both inclusion in general adult literacy programs and disability specific adult literacy programs is urgently needed to reach the goals for education and poverty eradication established by the new United Nations Convention on the Rights of Persons with Disabilities and by the Millennium Development Goals.In the early 1990s, UNESCO estimated that perhaps 97% of the worlds 650 million disabled persons were unable to read or write, leading to significant efforts throughout the developing world to ensure that all children with disabilities attended school through ‘inclusive education’ programmes. But what of the vast majority of persons with disabilities who now are adolescents or adults, well beyond the reach of classroom education, or the estimated 90% of disabled children who will still ‘age out’ of the system before such inclusive education is available in their communities? In this paper, we review findings from a global literature search on literacy of adults with disability in developing countries which shows that there is currently little in international development, education, health or disability research policies or programmes that addresses this issue. On the basis of these findings we argue that while inclusive education efforts for children are important, more attention also needs to be directed to providing literacy skills to illiterate and marginally literate disabled adolescents and adults. A concerted effort to improve access to basic literacy and numeracy skills through both inclusion in general adult literacy programmes and disability-specific adult literacy programmes is urgently needed to reach the goals for education and poverty eradication established by the new United Nations Convention on the Rights of Persons with Disabilities and by the Millennium Development Goals.

Disability and Poverty in Morocco and Tunisia: A Multidimensional Approach

Abstract Although a growing body of research is exploring the links between disability and poverty, the evidence that persons with disabilities are more likely to be poor than their non-disabled counterpart remains scarce. The causal relationship between disability and poverty has most often been considered in terms of disparities in income or living conditions. However, some research strongly suggests that disability is associated with deprivation in a number of other dimensions. To date, no study has examined these associations using large scale surveys with a wide range of wellbeing dimensions and indicators using a multidimensional approach. The present paper presents findings of three multidimensional poverty measures based on 17 indicators of deprivation collected through large-scale household surveys in Morocco and Tunisia. These indicators cover a wide range of dimensions of poverty such as health, education, employment, material well-being, social participation, psychological well-being and physical security. Results confirm that persons with disabilities are poorer than non-disabled people in both countries. The study shows that persons with disabilities, particularly girls and women, rural residents, and those with intellectual, mental or multiple disabilities are particularly deprived of basic capabilities and functionings and that stigma plays a role in this social injustice. Civil society organizations should take the lead to promote awareness of social and emotional well-being of persons with disabilities.

Delivering Education; Maintaining Inequality. The Case of Children with Disabilities in Afghanistan.

Education for children with disabilities in Afghanistan, particularly disabled girls, continues to lag behind despite laudable efforts of the Ministry of Education to promote universal access for all. The opportunity for education constitutes not just a means of achieving learning outcomes but also a space for social interaction, individual development and psychosocial support, which are paramount in Conflict-Affected Fragile States (CAFS). However, many persisting barriers still need to be overcome in Afghanistan to allow education for all and change negative attitudes towards education of children with disabilities. In this paper we argue that viewing education as a basic commodity, which is the widespread practice in CAFS, is not conducive to expanding human freedoms and capabilities. More specifically, through analyses of a national survey, we demonstrate that despite considerable resources, increasing access to education in Afghanistan has maintained processes of marginalisation of the already excluded.

Development and validation of the 34-Item disability screening questionnaire (DSQ-34) for use in low and middle income countries epidemiological and development surveys

Background Although 80% of persons with disabilities live in low and middle-income countries, there is still a lack of comprehensive, cross-culturally validated tools to identify persons facing activity limitations and functioning difficulties in these settings. In absence of such a tool, disability estimates vary considerably according to the methodology used, and policies are based on unreliable estimates. Methods and Findings The Disability Screening Questionnaire composed of 27 items (DSQ-27) was initially designed by a group of international experts in survey development and disability in Afghanistan for a national survey. Items were selected based on major domains of activity limitations and functioning difficulties linked to an impairment as defined by the International Classification of Functioning, Disability and Health. Face, content and construct validity, as well as sensitivity and specificity were examined. Based on the results obtained, the tool was subsequently refined and expanded to 34 items, tested and validated in Darfur, Sudan. Internal consistency for the total DSQ-34 using a raw and standardized Cronbach’s Alpha and within each domain using a standardized Cronbach’s Alpha was examined in the Asian context (India and Nepal). Exploratory factor analysis (EFA) using principal axis factoring (PAF) evaluated the lowest number of factors to account for the common variance among the questions in the screen. Test-retest reliability was determined by calculating intraclass correlation (ICC) and inter-rater reliability by calculating the kappa statistic; results were checked using Bland-Altman plots. The DSQ-34 was further tested for standard error of measurement (SEM) and for the minimum detectable change (MDC). Good internal consistency was indicated by Cronbach’s Alpha of 0.83/0.82 for India and 0.76/0.78 for Nepal. We confirmed our assumption for EFA using the Kaiser-Meyer-Olkin measure of sampling well above the accepted cutoff of 0.40 for India (0.82) and Nepal (0.82). The criteria for Bartlett’s test of sphericity were also met for both India (< .001) and Nepal (< .001). Estimates of reliability from the two countries reached acceptable levels of ICC of 0.75 (p<0.001) for India of 0.77 for Nepal (p<0.001) and good strength of agreement for weighted kappa (respectively 0.77 and 0.79). The SEM/MDC was 0.80/2.22 for India and 0.96/2.66 for Nepal indicating a smaller amount of measurement error in the screen. Conclusions In Nepal and India, the DSQ-34 shows strong psychometric properties that indicate that it effectively discriminates between persons with and without disabilities. This instrument can be used in association with other instruments for the purpose of comparing health outcomes of persons with and without disabilities in LMICs.

Vulnerability and mental health in Afghanistan: Looking beyond war exposure

This study examined the prevalence of mental distress among groups in Afghanistan considered to be at risk. Data were drawn from a representative cross-sectional disability survey carried out in Afghanistan including 5,130 households in 171 clusters throughout the 34 provinces of the country. The sample included 838 nondisabled control participants aged above 14, and 675 disabled participants. Results showed that various vulnerable groups (disabled people, the unemployed, the elderly, minority ethnic groups, as well as widowed, divorced or separated women) were at higher risk of experiencing mild to severe mental health problems. The adjusted odds ratio for war-related disability compared to nondisabled was 4.09 (95% confidence interval 2.09 to 7.99) for mild mental distress disorders, and 7.10 (3.45–14.5) and 14.14 (3.38–59.00) for moderate or severe mental distress disorders, respectively. Women with disabilities (whatever the cause of impairment) when compared with nondisabled men, as well as poorer segments of society compared to the richest, had a higher prevalence of mental health problems. Women with non-war-related disabilities compared with nondisabled men were respectively 3.35 (1.27–8.81) and 8.57 (3.03–24.1) times more likely to experience mild or moderate mental distress disorders. People who experience multiple vulnerabilities are more at risk of deteriorating mental health in conflict zones. The study shows that mental health, in times of war, is influenced by a combination of demographic and socioeconomic characteristics linked to social exclusion mechanisms that were in place before the conflict began and that are redefined in relation to the changing social, cultural, and economic contexts. Mental health policies and programmes must prioritise the most vulnerable segments of Afghan society.

The Accountability–Well-Being–Ethics framework: A new philosophical foundation for occupational therapy: Le cadre Accountability–Well-Being–Ethics : un nouveau fondement philosophique pour l’ergothérapie

Background. The context that supported occupational therapy’s inception has been replaced with new challenges brought on by globalization and dramatic changes in health care. Thus, the profession’s philosophical grounding needs to be reframed to (a) achieve balance between science-driven and holistic elements, (b) operate within larger contexts on problems brought on by sociopolitical and natural determinants of health, and (c) maintain an ethical identity across all arenas of practice. Purpose. This paper presents a brief discussion of the philosophical underpinnings in occupational therapy’s history, outlines new global challenges for the profession, and proposes a new framework to address these challenges through education, practice, and research. Key Issues. Occupational therapy finds itself practising in a growing number of middle- and low-income countries where its roles and values need to be context and culture specific. Implications. The Accountability–Well-Being–Ethics framework guides the three domains of education, research, and practice to be relevant in an increasingly complex world.

Rethinking Children’s Disabilities through the Capability Lens: A Framework for Analysis and Policy Implications

This chapter has two main aims. The first is to propose a new framework for policy that complements the evolving capabilities approach (CA) developed in Chapter 2. The second is to focus specifically on children with disabilities in developing countries and to revisit current models of disability in this context. The case study of children’s well-being in Afghanistan discussed previously in this book is used to illuminate the discussion.