Julia de Kadt

Background: Effective disability inclusion in education requires that teachers and others in the education system have access to accurate and reliable information about children's disabilities. Washington Group (WG) tools are increasingly used in low- and middle-income countries, however, the feasibility and accuracy of such tools is poorly understood. The aim of this study was to assess the feasibility of using WG tools to assess functional difficulty (FD) in children in rural Sierra Leone and to examine the prevalence of FD. Methods: Class teachers in eight schools completed an FD assessment for each child on their class register using either the WG Short Set (WG-SS) or Child Functioning Module—Teacher Version (CFM-TV). Teacher experiences with the tools were explored during focus group discussions. The prevalence of FD was explored using descriptive statistics. Results: Teachers found both tools broadly feasible, although there was some concern with the length and complexity of the CFM-TV. A total of 30 teachers used the WG-SS to assess 1346 children ages 5–17 y; 1.1% were reported to have FD. A total of 35 teachers used the CFM-TV to assess 1738 children; 14.9% were reported to have FD. Conclusions: The use of WG tools by teachers is feasible for generating data on children's FD and potentially valuable for effective disability inclusion.

Background: Disability‐inclusive early childhood development and education (ECDE) plays a crucial role in ensuring that all children, including those with disabilities, reach their developmental potential. However, there is little data on the prevalence of disability in mainstream ECDE in most low‐ and middle‐income countries (LMICs), or on early learning and developmental outcomes of children with disabilities in these classrooms.Methods: Data were collected on 1756 children aged 3–9 years enrolling in ECDE at 18 schools in Homa Bay or Turkana Counties, Kenya, at the start of the 2021 and 2022 school years. The UNICEF/Washington Group Child Functioning Module (CFM) measured the prevalence of functional difficulty, and the International Development Early Learning Assessment (IDELA) measured child development and learning.Results: Mainstream classes in sampled preschools included significant proportions of children with functional difficulties (19.9% in Homa Bay; 8.8% in Turkana). In both sites, the odds of having at least one functional difficulty were significantly higher among those aged 5 and above (OR = 2.82 for Homa Bay; 5.76 for Turkana). Multivariate regression found no relationship between functional difficulty and sex or household income.Among children aged 2–4 years in Homa Bay, functional difficulty was most often reported in the domain of controlling behaviour (4.4%), whereas in Turkana, mobility (1.4%) was most common. For children aged 5 and above in Homa Bay, difficulty with accepting change (11%) was most frequently reported, whereas in Turkana it was anxiety (6%).Median IDELA scores were 49 in Homa Bay and 31 in Turkana. Scores increased with child age. Regression models accounting for age‐ and school‐level clustering found no statistically significant differences by sex. Functional difficulties were associated with lower median IDELA scores in Turkana only (β = −5.44 [−8.86, −2.02]).Conclusion: Findings highlight the importance of appropriate, sustainable support for inclusive ECDE in both settled communities and refugee settings.

Introduction: Continuity of care is an attribute of high-quality health systems and a necessary component of chronic disease management. Assessment of health information systems for HIV care in South Africa has identified substantial rates of clinic transfer, much of it undocumented. Understanding the reasons for changing sources of care and the implications for patient outcomes is important in informing policy responses. Methods: In this secondary analysis of the 2014 – 2016 I-Care trial, we examined self-reported changes in source of HIV care among a cohort of individuals living with HIV and in care in North West Province, South Africa. Individuals were enrolled in the study within 1 year of diagnosis; participants completed surveys at 6 and 12 months including items on sources of care. Clinical data were extracted from records at participants’ original clinic for 12 months following enrollment. We assessed frequency and reason for changing clinics and compared the demographics and care outcomes of those changing and not changing source of care. Results: Six hundred seventy-five (89.8%) of 752 study participants completed follow-up surveys with information on sources of HIV care; 101 (15%) reported receiving care at a different facility by month 12 of follow-up. The primary reason for changing was mobility (N=78, 77%). Those who changed clinics were more likely to be young adults, non-citizens, and pregnant at time of diagnosis. Self-reported clinic attendance and ART adherence did not differ based on changing clinics. Those on ART not changing clinics reported 0.66 visits more on average than were documented in clinic records. Conclusion: At least 1 in 6 participants in HIV care changed clinics within 2 years of diagnosis, mainly driven by mobility; while most appeared lost to follow-up based on records from the original clinic, self-reported visits and adherence were equivalent to those not changing clinics. Routine clinic visits could incorporate questions about care at other locations as well as potential relocation, particularly for younger, pregnant, and non-citizen patients, to support existing efforts to make HIV care records portable and facilitate continuity of care across clinics. Trial registration: The original trial was registered with ClinicalTrials.gov, NCT02417233, on 12 December 2014.

Depressive symptoms are a major burden of disease globally and is associated with violence and poverty. However, much of the research linking these conditions is from resource-rich settings and among smaller, clinical samples. Secondary data from a household survey in Gauteng Province of South Africa examines the cross-sectional association between adult women’s elevated depressive symptoms and markers of violence. Using tablet computers, participants self-completed interview modules to screen for depressive symptoms (Patient Health Questionnaire 2-item screener), childhood exposure to physical and sexual abuse (Childhood Trauma Questionnaire 4-item index), as well as past-year exposure to sexual or intimate partner violence (SIPV; WHO Multicountry Study instrument 4-item index). Socio-economic status, food security, education, and income were self-reported. Representative data at the ward level allows for modeling of results using survey commands and mixed-level modeling. Of the 7,276 adult women participating in the household survey, 42.1% reported elevated depressive symptoms. A total of 63.9% reported childhood violence exposure and 5.3% had past-year SIPV. Multi-level modeling suggests that violence is a strong predictor of depressive symptoms. Childhood abuse alone increases the odds of high depressive symptomology, after controlling for individual-level markers of poverty and neighborhood of residence (aOR 1.31, 95%, CI 1.17–1.37). Combined exposure to childhood abuse and past-year SIPV increased odds of reporting elevated depressive symptoms (aOR 2.05, 95%, CI 1.54–2.71). Ward characteristics account for 6% of the variance in depressive symptoms, over and above the contributions of household food security and socio-economic status. Exposure to violence in childhood and past-year SIPV were associated with depressive symptoms among women. These associations persist after controlling for socio-economic markers and latent neighborhood characteristics, which also had significant association with elevated depressive symptoms. These data suggest that efforts to reduce the burden of depressive symptoms may benefit from approaches that prevent violence against women and children.

This paper demonstrates a simple methodological sequence for the statistical calculation of a context-sensitive quality of life index especially suitable for use in the Global South, i.e. lower and middle income countries. We draw on the large (n = 24,889), area-sampled, survey dataset of the fifth Quality of Life Survey (QoL V, 2017/18) of South Africa’s Gauteng province, conducted by the Gauteng City-Region Observatory. Using overtly exploratory analysis, and a fully reflective conception of indicators, we apply exploratory factor analysis (EFA) in two stages to generate our model, while defending our approach methodologically and empirically and indicating its philosophical foundations. We contrast this approach to previous analyses using the QoL I (2010) data, which defined their dimensions and assign their indicators in advance, drawing on literature and indexes largely from the Global North. We ran series of EFAs on 60 longitudinally available variables from the QoL V data set. This allowed us to determine the optimal number of factors/dimensions, guided by established criteria and the interpretability of the grouped indicators. Each dimension score is calculated arithmetically, using the indicators’ factor loadings as weights. Then the dimensions, weighted by their eigenvalues, are aggregated into the composite index, scaled to run from 0 to 100. The resulting seven-dimension, 33-indicator model was validated through confirmatory factor analysis (CFA) on the QoL V data; and its configural invariance, i.e. whether the pattern of indicators amongst the factors holds over time, was checked against the two previous QoL datasets and confirmed. This validates the ability of the approach outlined to generate a stable index. Analysis of the resulting quality of life index by race and municipality reveals trends consistent with the South African context. Overall, the White population group has the highest measured quality of life index, followed in turn by the Indian/Asian, Coloured and Black African population groups. Changes in the quality-of-life ranking of the nine municipalities comprising Gauteng province may be observed over time, using the validated previous models. The value of the exploratory approach in enabling context to influence the index construction is highlighted by the emergence of a distinct dimension of bottom-up political voice, which is relevant for democratic governance.