Brief model disability survey: 2019 results for India, Lao People's Democratic Republic and Tajikistan

Brief model disability survey: 2019 results for India, Lao People’s Democratic Republic and Tajikistan Brief model disability survey: 2019 results for India, Lao People’s Democratic Republic and Tajikistan Brief model disability survey: 2019 results for India, Lao People’s Democratic Republic and Tajikistan ISBN 978-92-4-002362-8 (electronic version) ISBN 978-92-4-002363-5 (print version) © World Health Organization 2021 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. 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In no event shall WHO be liable for damages arising from its use. iii CONTENTS 1 INTRODUCTION 1 2 METHODOLOGY 2 2.1 Sample design and sample size 2 2.1.1 India 3 2.1.2 Lao People’s Democratic Republic 3 2.1.3 Tajikistan 4 2.1.4 Selection of households 5 2.2 Project 6 2.3 Disability and capacity 6 2.4 Questionnaire 7 2.5 Calculation of disability scale 8 2.6 Gallup indices 9 3 MAIN FINDINGS 10 3.1 Demographic characteristics 11 3.2 Health conditions 14 3.3 Assistive technology 16 3.4 Disability and capacity 16 4 RESULTS BY DISABILITY LEVEL 19 4.1 Demographic characteristics 19 4.2 Health 23 4.3 Assistive technology 30 4.4 Aspects of physical environment 38 4.5 Aspects of social environment 41 4.6 Political situation 44 4.7 Economic situation 46 4.8 Well-being 49 5 POLICY IMPLICATIONS 52 6 REFERENCES 55 7 ANNEXES 56 7.1 Annex 1. Overview of variables 56 7.2 Annex 2. Statistical analysis used in the Brief MDS 71 iv 1 1 Introduction The world is facing important trends associated with an increase of disability in populations, especially a rise in noncommunicable diseases (NCDs) and the rapid ageing of the world population. Estimates from the WHO World report on disability (1) show that 15% of the global population experiences significant disability. The level of disability in countries and regions is influenced, however, not only by trends in health conditions but also by physical, human-built, attitudinal and sociopolitical barriers, such as the negative attitudes of others, inaccessible transportation and public buildings, poor social support or limited access to health services. The challenges that disability creates for people’s lives and well-being are compounded by a critical lack of access to assistive devices that would enable individuals to lead autonomous, dignified and productive lives. Assistive devices are powerful tools that maintain and improve an individual’s functioning and independence, promoting overall well-being. However, WHO estimates that currently only 1 in 10 people in such need have access to assistive products.1 This gap between prevalence of individuals living with disability and the deficit in access to assistive devices is striking. Interventions are essential. Interventions that target disability in a country can be directed at improving or optimizing functioning of individuals, such as through provision of rehabilitation services, or at lowering environmental barriers, for example through dedicated transportation, employment or accessible health care policies. Good quality and comprehensive disability data are essential. Policy development and planning of public health actions and services require a precise understanding of disability, including 1 See: https://www.who.int/news-room/fact-sheets/detail/assistive-technology 2 detailed information on needs for assistive technology, inequalities, barriers and needs faced by persons experiencing different levels of disability. The Model Disability Survey (MDS) was developed to collect such data. Data generated by the MDS are being used by countries to quantify the impact on disability of health conditions or impairments, and of the environment, and also to better understand the degree to which individuals with disability have access to, and use, assistive devices. This allows countries to determine which interventions and policies will likely produce the most benefit for different sections of the population. 2 Methodology 2.1 Sample design and sample size In the three countries where the study was conducted (India, Lao People’s Democratic Republic2 and Tajikistan), the Brief Model Disability Survey (Brief MDS) was included as a module within the Gallup World Poll (2). Since 2005, The Gallup World Poll has regularly surveyed people in over 160 countries, representing more than 99% of the world’s population aged 15 years and older, using randomly selected, nationally representative samples. The sampling frame in the World Poll included the total non-institutionalized population aged 15 years and older. For this study, oversamples were conducted in Lao People’s Democratic Republic and Tajikistan. A brief description of the sampling design in all three countries is provided below. 2 Due to the repeated references to Lao People’s Democratic Republic throughout this report, the abbreviated “Lao PDR” has been adopted in tables, figures and when giving statistical information. 3 2.1.1 India Gallup used a stratified multistage cluster sampling design for obtaining nationally representative samples. Due to their extreme geographical location and sparse population, the north-eastern states and the union territories were excluded from the sample, as were the following islands: Andaman & Nicobar Islands, Arunachal Pradesh, Dadra and Nagar Haveli, Daman and Diu, Lakshadweep, Manipur, Meghalaya, Mizoram, Nagaland, Puducherry, Sikkim, and Tripura. The excluded population from these areas was estimated to be less than 10% of the total target population. The sample was stratified by states/territories and by an urban/rural classification of settlements within those geographies. Gallup followed the rule of selecting a minimum of two primary sampling units (PSUs) per stratum to avoid difficulties with variance estimation. For this reason, not all states were subdivided into urban and rural. Furthermore, for the same reason, some smaller states were merged with their neighbours. As a result, 33 strata were created for India. The sample was allocated to the 33 strata proportionally to the population age group of ≥15 years, using data from the 2011 census. The selection was carried out in two stages within the strata. In the first stage, districts served as PSUs and were selected using the PPS method employing total population numbers from the 2011 census. For a total sample size of 3000, 180–190 PSUs were selected. In the second stage, wards in the urban domain and villages in the rural domain served as secondary sampling units (SSUs). SSUs were also selected using the PPS method. In total, for 3000 interviews, 300 SSUs were selected with ten interviews conducted in each SSU. 2.1.2 Lao People’s Democratic Republic A stratified cluster sampling design was used for obtaining a nationally representative sample in Lao People’s Democratic Republic. The study covered 17 of 18 provinces and excluded the Xaisomboun Province and communes that were unreachable and/or had security considerations. Estimated coverage for this study was 90% of the total adult population (i.e. individuals aged ≥15 years). The total target population was stratified first by the 17 provinces. Larger provinces were further stratified by an urban/rural classification of settlements. Smaller 4 provinces were not subdivided in order to follow Gallup’s rule of selecting a minimum of two PSUs per stratum. The sample was distributed across the strata proportionally to the size of the adult population; data from the 4th Lao Population and Housing Census (2015)3 was used as a measure of population size. Communes, being the smallest territorial units, were directly selected within the strata using the PPS method; 313 PSUs were selected, with eight interviews completed in each, to achieve the total sample size of 2500. 2.1.3 Tajikistan In order to obtain a nationally representative sample, Gallup used a multi-stage cluster probability sampling approach. No geographical exclusions were made during sampling. The sample was stratified by five administrative regions, urban rural division and six settlement size categories: (i) ≥1 million; (ii) 500 000–999 000; (iii) 100 000–499 000; (iv) 50 000–99 000; (v) 10 000–49 000; (vi) <10 000. Gallup followed the rule of selecting a minimum of two PSUs per stratum to avoid the difficulty of variance estimation. Using this rule and cross-classification of the two stratification variables created 13 strata in Tajikistan. The sample size was allocated across the 18 strata proportionally to total population. Data from the 2010 population census were used as a measure of the size of each stratum for purposes of allocation. The sampling within strata was conducted in two stages. In the first stage, cities, towns and rural villages, served as PSUs. The selection was carried out with the probability proportional to size (PPS) method, with population sizes of selection units drawn from the 2010 population census of Tajikistan. For a sample size of 3000, 329 PSUs were selected. The second stage of selection was pursued in larger settlements only – with a population of more than 20 000 – where grid maps of settlements were used as secondary sampling units. Using satellite data, the population density of grids within selected settlements were estimated, and the PPS method for selection was used. For smaller settlements, no second stage sampling units were 3 See: https://lao.unfpa.org/en/publications/provisional-report-4th-lao-population-and-housing-census-2015 5 applied. In total, 375 ultimate clusters were selected for this study with eight interviews per cluster. 2.1.4 Selection of households In all three countries, household selection involved the selection of starting points within a PSU or ultimate cluster. Gallup had developed random-route procedures that included a set of rules for interviewers to identify in which direction they needed to move from their starting point, selecting every nth household until eight to ten interviews were completed in each ultimate cluster. Once interviewers had selected a household, they listed all household members aged 15 years or older currently living in the household using the computer-assisted personal interviewing (CAPI) system; the computer programme randomly selected one member from this list to interview. The mode of implementation meant that individuals with severe vision impairment (i.e. an inability to see the show cards) and hearing impairment (i.e. needing the survey to be read out from the tablets) were excluded from the survey. Interviewers made up to three attempts to select an eligible respondent and complete an interview. If, after three attempts, interviewers failed to obtain an interview in any of the households originally selected, they selected replacements by continuing along the same route from the previous originally selected household. Gallup collected individual background information for each survey participant. Demographic information varied from country to country as was culturally appropriate, although it would generally include age, sex, employment status, number of adults and children in the household and educational level. Gallup also provided identifiers which permitted disaggregation of the data by rural and urban regions. 6 2.2 Project In 2018, the WHO Brief Model Disability Survey (Brief MDS) was integrated into the Gallup World Poll4 questionnaire and administered in face-to-face household interviews in India, Lao People’s Democratic Republic and Tajikistan. The combination of the Brief MDS with the World Poll variables allowed for the disaggregation of key World Poll indicators by level of disability, thus allowing WHO to go beyond disaggregation and analyse the complex ways in which all of these societal factors influence disability, and vice versa. Additionally, the infrastructure of the Gallup World Poll gave the opportunity for frictionless scaling-up of this project to a global level in the future. The results of this project, funded by USAID, give governments the opportunity to prioritize policies to address barriers in the community that persons with disability experience, rather than simply providing data on how many persons with disability are, or are not, accessing particularly services. The WHO Brief MDS goes beyond traditional methods of disability data collection by including information not only on the state of an individuals’ health, but also on the barriers in the environment that they may experience, as well as their access to, use and need of assistive products. The level of detail in the data allows for the calculation of a scale of disability, so that survey indicators can be disaggregated not only by “with disability” and “without disability,” but also by varying degrees of disability. With this module, the differences in the issues faced by those with mild, moderate or severe disability and those without disability can be analysed. 2.3 Disability and capacity The MDS is grounded in the International Classification of Functioning, Disability and Health (ICF) (3). The ICF defines “capacity” as the synthesis of all intrinsic physical and mental capacities of a person, determined by his or her health conditions or impairments; and 4 See: https://www.gallup.com/analytics/232838/world-poll.aspx 7 “disability” as the outcome of the interaction between a person’s health condition(s) and the physical, human-built, attitudinal and sociopolitical environment in which that person lives. Disability is therefore not solely the result of an internal attribute of a person due to impairments (e.g. lack of a limb) or specific health conditions (e.g. Down syndrome). In the MDS, disability is also defined as a continuum, ranging from no disability to very high levels of disability. Disability is therefore a matter of degree, and the experience of disability is diverse and universal. For instance, a person who has suffered a stroke might experience impairments in muscle power (body function) and paralysis of arms and legs (body structure), limitations in walking and restrictions at work (activities and participation). If the environment is facilitating – for example, treatment is timely, appropriate, and of high quality, and the family is supportive – then there is a beneficial impact on the level of disability experienced by the individual. 2.4 Questionnaire For this project, the Brief MDS was integrated into the 2018 Gallup World Poll in India, Lao People’s Democratic Republic and Tajikistan. The MDS is a general population survey that allows for a direct comparison of the needs and barriers faced by people with differing levels of disability, including those without disability. The MDS operationalizes the ICF by using questions that capture information relevant to the ICF’s conceptualization of disability. Following calls from WHO Member States for a version of the MDS that could be integrated into existing and regularly implemented surveys, the Brief MDS was developed in 2016. The Brief MDS is a disability module estimated to take approximately 12 minutes to complete. The module allows for the calculation of a disability scale and the disaggregation of key survey indicators by level of disability. Gallup World Poll is an annual global survey vehicle used to collect data representative of the world's adult population. Since 2005, Gallup has conducted surveys annually in approximately 160 countries worldwide and in 145 languages, employing a gold-standard methodology that 8 provides a window into the thoughts and behaviours of the world’s population through nationally representative samples. The Gallup World Poll contains numerous questions on a variety of topics such as economic empowerment, access to clean water and food, citizen engagement, and public safety. It is the only global study of its kind, and is used as a primary data source by numerous global organizations, such as the United Nations, the World Bank and the Organization for Economic and Co-operation and Development (OECD). It has also been instrumental in shaping country-level policy and monitoring – for example the monitoring of financial inclusion indicators by G20 nations (3). The definition of all the variables presented in this report is provided in 7.1. 2.5 Calculation of disability scale The scores are estimated in a scale that ranges from 0 (no disability) to 100 (high levels of disability) using Item Response Theory (IRT). Further details on this calculation are included in 7.2. A pooled score was estimated using the pooled data from the three countries. The disability distribution and cut-offs were calculated across the pooled data. The cut-offs were used to identify persons experiencing no, mild, moderate and severe disability in each country. The calculation of cut-offs used in this report is shown in Table 1. All results are presented disaggregated by disability level. Table 1. Cut-offs used to identify persons with no, mild, moderate and severe disability in the MDS Target level Cut-off criteria No Score < Mean – 1SD or Score = 0 Mild Mean – 1SD ≤ Score < Mean Moderate Mean ≤ Score < Mean + 1SD Severe Score ≥ Mean + 1SD Score: metric score; Mean: sample mean of the score; 1SD: one standard deviation of the given score 9 2.6 Gallup indices Gallup calculates a number of standardized indices from the Gallup World Poll data that span multiple political, social and economic topics. These indices aggregate singular questions from the World Poll of the same topic, and allow for the comparison of high level results across settings and across time. This report shows the results of several of these indices, disaggregated by disability level. A full description of each index can be found in 7.1. 10 3 Main findings Demographic characteristics - Predominance of young adults: more than 70% of people aged 18–49 years - Majority of the population with low education: more than half of the population had elementary or less education in India and Lao PDR, and had secondary education in Tajikistan - Most of the population as married: More than 2/3 of the population reported as married - Predominance of self-employment or out of workforce: Most of the population was out of the workforce in India and Tajikistan and was self-employed in Lao PDR Health conditions - Health conditions very common: nearly 2/3 (64%) of the adult population in Lao PDR reported having at least one health condition. This was observed in 47% of the population in Tajikistan, and 37% in India - Many individuals with more than one health condition: the prevalence of multimorbidity, i.e. 2 or more health conditions, was 43% in Lao PDR, 29% in Tajikistan and 23% in India - Health problems very frequent: the occurrence of health problems that limited individuals from doing things that others of the same age would normally do was similar across the three countries, affecting almost ¼ of their populations - High occurrence of musculoskeletal conditions and mental disorders: among the health conditions investigated, the highest burden across the three countries was observed for musculoskeletal conditions (e.g. back pain) and mental disorders (e.g. depression and anxiety) Assistive devices - Few individuals using assistive devices: approximately 1/5 of the adult population in India (19%), Lao PDR (17%) and Tajikistan (19%) reported using assistive devices - Low occurrence of problems with use of assistive products: among users, 17% in India, 13% in Lao PDR and 10% in Tajikistan faced problems with the use of products - Low partially unmet need: additional need of assistive devices was reported as 17% (India), 14% (Lao PDR) and 16% (Tajikistan) among individuals who already use products - Few individuals with completely unmet need: the need of assistive devices was reported as 9% (India), 17% (Lao PDR) and 6% (Tajikistan) among individuals who do not use products Key findings Among the adult population of the three countries, prevalence of severe disability was reported as16% in India, 23% in Lao PDR and 8% in Tajikistan. Moderate disability was reported as 35% (India), 56% (Lao PDR) and 24% (Tajikistan) 11 3.1 Demographic characteristics Similar proportions of men and women were observed across the three countries. The age distribution was similar in the countries, with most of the population being 18–49 years of age; not highly educated (highest proportion obtained elementary education or less in India and Tajikistan, and secondary education in Tajikistan); married (more than 60% in each country); out of the workforce (not employed during the past seven days; not looking for work; and/or not available to start work) in India and Tajikistan, and self-employed in Lao PDR; living in small town/village in India and Lao PDR (more than 40%) and in rural area in Tajikistan (73%); and Hindu (82%), Buddhist (72%) and Muslim (95%) in India, Lao PDR and Tajikistan, respectively (Table 2). Table 2. Demographic characteristics of the sample in India, Lao People’s Democratic Republic and Tajikistan (weighted percentages presented) Characteristic India Lao People’s Democratic Republic Tajikistan N % 95% CI N % 95% CI N % 95% CI Gender Male 1721 51.5 49.1;53.8 1151 49.7 47.3;52.1 1173 49.3 46.7;51.9 Female 1279 48.5 46.2;50.9 1353 50.3 47.9;52.7 1827 50.7 48.1;53.3 Age group (years) 15–17 142 6.6 5.5;7.8 106 7.9 6.4;9.3 188 9.0 7.5;10.4 18–29 854 31.0 28.8;33.1 642 35.5 33.0;38.0 854 36.1 33.9;38.3 30–49 1259 39.2 36.9;41.5 1083 36.5 34.3;38.7 1178 35.4 33.5;37.4 50–64 541 17.0 15.3;18.8 491 14.9 13.5;16.3 586 14.6 13.2;16.0 65–98 204 6.2 5.0;7.3 179 5.2 4.3;6.0 193 4.8 4.1;5.6 ³99 0 0.0 0;0 0 0.0 0;0 1 0.1 0;0.3 Education level Elementary or less 1818 53.7 50.6;56.8 1511 53.3 50.2;56.3 644 27.0 24.5;29.4 Secondary 952 41.5 38.7;44.4 755 36.0 33.3;38.7 1628 59.3 56.8;61.8 Tertiary 225 4.5 3.5;5.5 234 10.6 8.9;12.2 728 13.7 12.5;15.0 Marital status Single/never married 594 23.7 21.7;25.7 361 22.2 19.9;24.6 572 25.1 22.8;27.3 Married/ domestic partner 2166 69.0 67.0;70.9 1869 70.4 68.0;72.9 2072 66.2 63.9;68.6 Separated/divorced 21 0.6 0.3;0.9 100 2.9 2.2;3.5 156 4.1 3.3;5.0 Widowed 216 6.6 5.5;7.7 164 4.2 3.5;4.9 196 4.4 3.6;5.3 Employment status no 872 26.9 24.3;29.5 362 15.1 13.4;16.9 515 14.6 12.8;16.3 Employed full time for self 370 10.8 9.0;12.5 1087 43.1 40.8;45.4 110 4.0 2.9;5.0 Employed part time do not want full time 257 7.7 6.2;9.1 537 20.1 18.3;21.9 268 8.8 7.4;10.2 Unemployed 135 4.4 3.3;5.5 7 0.2 0;0.3 171 6.6 52.7;58.3 Employed part time want full time 301 10.3 8.6;12.1 381 15.8 14.0;17.6 299 10.5 8.8;12.3 12 13 Characteristic India Lao People’s Democratic Republic Tajikistan N % 95% CI N % 95% CI N % 95% CI Out of workforce 1065 40.0 37.1;42.8 130 5.7 4.6;6.8 1637 55.5 5.4;7.8 Setting Rural/farm 1260 40.6 35.0;46.3 952 37.4 33.1;41.7 2288 72.9 71.6;74.3 Small town/village 1360 46.4 40.3;52.6 1080 43.8 38.9;48.6 456 17.1 16.0;18.3 Large city 240 8.0 4.2;11.8 248 9.8 6.8;12.7 256 9.9 0;0 Suburb of large city 140 5.0 1.7;8.2 224 9.1 6.0;12.1 0 0.0 8.9;10.9 Religion Christian 13 0.9 0.3;1.6 44 1.9 0.8;3.0 2 0.0 0;0.1 Islam 343 12.9 9.4;16.4 1 0.1 0;0.2 2989 99.5 99.2;99.8 Hinduism 2521 82.4 78.7;86.0 0 0.0 0;0 1 0.1 0;0.2 Buddhism 46 1.6 0.7;2.6 1828 71.6 68.0;75.3 0 0.0 0;0 Judaism 0 0.0 0;0 0 0.0 0;0 0 0.0 0;0 Secular/non-religious 0 0.0 0;0 0 0.0 0;0 2 0.1 0;0.3 Other 77 2.2 1.3;3.0 594 25.2 21.8;28.5 0 0.0 0;0 3.2 Health conditions Back pain was the most commonly reported health condition, with a prevalence of 44% in Lao PDR, 31% in Tajikistan and 19% in India. Other conditions with high prevalence were: anxiety (17%) and depression (9%) in India; anxiety (20%) and tinnitus (14%) in Lao PDR; and hypertension (14%) and depression (12%) in Tajikistan. The highest prevalence of reporting one or more health conditions among the 15 conditions investigated was found in Lao PDR, where almost 2/3 of the adult population reported having at least one health condition, while rates of 47% were found in Tajikistan, and 37% in India. The prevalence of reporting two or more chronic conditions was 43% in Lao PDR, 29% in Tajikistan, and 23% in India. Despite the pronounced differences in the prevalence of chronic conditions between the three countries, the prevalence of health problems (i.e. health problems that prevented the individual from doing things that others of the same age could do) was similar across the three countries, with nearly 1/4 of the population reporting such problems. (Table 3). 14 Table 3. Prevalence of health conditions in India, Lao People’s Democratic Republic and Tajikistan (weighted percentages presented) Health conditions India Lao People’s Democratic Republic Tajikistan N % 95% CI N % 95% CI N % 95% CI Vision loss 263 7.4 6.1;8.7 373 12.2 10.8;13.6 299 7.7 6.5;8.8 Hearing loss 148 3.9 3.0;4.8 204 6.3 5.3;7.3 114 3.0 2.2;3.7 Hypertension 267 7.9 6.4;9.3 345 11.1 9.8;12.3 563 14.4 13;15.9 Heart diseasea 92 2.2 1.5;2.9 236 7.3 6.2;8.5 303 7.9 6.8;9.0 Stroke 66 1.3 0.9;1.8 43 1.3 0.8;1.7 48 1.4 0.9;1.8 Diabetes 123 3.4 2.5;4.2 97 3.1 2.3;3.9 76 1.8 1.3;2.3 Arthritis/ arthrosis 291 8.1 6.5;9.6 389 12.1 10.7;13.5 379 10.3 8.8;11.7 Chronic bronchitis or emphysema 113 3.0 2.3;3.7 100 3.1 2.3;3.8 113 2.9 2.2;3.6 Asthma or allergyb 157 4.1 3.3;4.9 245 8.4 7.1;9.6 206 6.0 4.8;7.1 Back pain 656 18.8 16.5;21.2 1224 44.5 42.1;46.9 1067 31.0 28.4;33.7 Depression 371 9.5 8.2;10.9 305 11.8 10.2;13.3 419 12.2 10.3;14.0 Anxiety 612 17.1 14.8;19.4 511 19.8 17.9;21.7 371 10.7 9.2;12.3 Amputation 78 1.5 0.9;2.0 85 2.9 2.2;3.6 143 4.2 3.2;5.2 Trauma 153 3.8 2.9;4.7 243 10.1 8.7;11.4 111 3.8 2.8;4.7 Tinnitus 125 3.3 2.5;4.1 417 14.5 12.9;16.2 387 11.5 9.9;13.2 ³ 1 health conditions 1040 37.3 34.4;40.2 1514 63.7 61.4;66.0 1495 46.9 43.9;49.9 ³ 2 health conditions 658 22.6 20.4;24.9 1026 42.6 40.2;44.9 982 29.5 27.0;31.9 Health problems 802 24.0 21.4;26.6 685 23.1 21.2;24.9 817 24.9 22.7;27.1 a Heart diseases, coronary diseases, heart attack; b Allergic respiratory diseases 15 3.3 Assistive technology Prevalence in the use of assistive devices was reported as 19% (India), 17% (Lao PDR) and 19% (Tajikistan) by the overall adult population. Among the individuals who used assistive devices, 17% (India), 13% (Lao PDR) and 10% (Tajikistan) faced problems with their devices and 17%, 14% and 16% respectively in India, Lao PDR and Tajikistan reported needing additional products (partially unmet need). The highest prevalence of need of assistive devices among those who did not already use them (completely unmet need) was observed in Lao PDR (17%) followed by India (9%) and Tajikistan (6%) (Table 4). Table 4. Prevalence of use, partially unmet need, and completely unmet need of assistive devices in India, Lao People’s Democratic Republic and Tajikistan (weighted percentages presented) Use of assistive technology (AT) India Lao People’s Democratic Republic Tajikistan N % 95% CI N % 95% CI N % 95% CI Use of AT 650 19.2 17.2;21.3 480 17.3 15.7;18.9 680 19.0 16.6;21.3 Facing problems using AT 95 17.0 12.7;21.2 54 12.9 9.4;16.5 71 10.0 7.2;12.8 Partially unmet need of AT 94 16.8 13.6;20.0 66 13.7 10.1;17.3 110 16.1 12.1;20.1 Completely unmet need of AT 219 9.2 7.7;10.6 388 16.6 14.8;18.5 165 5.8 4.6;6.9 3.4 Disability and capacity Figure 1 shows the disability continuum of the pooled disability scores of India, Lao PDR and Tajikistan, ranging from low levels of disability (0) to very high levels (100). This continuum was then divided into four categories (no disability, mild disability, moderate disability, and severe disability) based on the cut-offs described in Table 1. The cut-offs were calculated as 5.6 (no/mild), 27.8 (mild/moderate) and 50.0 (moderate/severe). A higher proportion of individuals with moderate disability was observed in Lao PDR compared to India and Tajikistan. 16 17 Similar trends were observed for the distribution of the capacity scores across all three countries (Figure 2). The cut-off points of 2.0, 23.4 and 44.8 were used to classify individuals as of mild, moderate and severe capacity levels, respectively. Figure 1. Disability continuum (pooled scores of India, Lao People’s Democratic Republic, and Tajikistan) Figure 2. Capacity continuum (pooled capacity scores of India, Lao People’s Democratic Republic, and Tajikistan) 18 Figure 3 shows the disability prevalence in each country. A higher prevalence of moderate and severe disability was observed in Lao PDR compared India and Tajikistan, with more than half of individuals in Lao PDR reporting moderate disability and nearly ¼ reporting severe disability. Similar trends were observed for the capacity prevalence across all three countries (Figure 4). Figure 3. Disability prevalence by country Figure 4. Prevalence of capacity levels by country 19 4 Results by disability level 4.1 Demographic characteristics Figure 5 through Figure 11 show the demographic characteristics of the study populations within disability levels. A slightly higher proportion of women was observed among individuals with severe disability levels in India and Tajikistan; in Lao PDR the proportion was similar among men and women (Figure 5). - Severe disability more common among women in India and Tajikistan: there was a slightly higher proportion of women among individuals with severe disability, except in Lao PDR where the proportion of men and women was the same - Severe disability frequent in older individuals: there was a higher proportion of older individuals among those with severe disability compared to those with no or mild disability - Most individuals with severe disability lower educated: low education level was disproportionately more common in individuals with severe disability - The majority of individuals with severe disability out of the workforce: high inequalities in the employment situation was observed in persons with severe disability: 48% (India) and 78% (Tajikistan) were out of the workforce, compared to 40% (India) and 55% (Tajikistan) in persons with no disability. In Lao PDR, no difference was observed: 8% of individuals with severe disability and 7% with no disability were out of the workforce - Low income among individuals with severe disability: individuals with moderate and severe disability were predominantly in the lowest income quintiles Key findings 20 Figure 5. Distribution of sex within disability levels A higher proportion of older individuals was observed among persons with moderate and severe disability compared to those with no and mild disability. However, most individuals with moderate and severe disability were adults (i.e. aged18–49 years) (Figure 6). Figure 6. Distribution of age within disability levels Across the three countries, a very small proportion of highly educated individuals was observed among those with moderate and severe disability compared to no and mild disability. The 21 predominant education level among persons with severe disability in India and Lao PDR was elementary or less, while in Tajikistan secondary education was predominant (Figure 7). Figure 7. Distribution of education within disability levels Individuals with moderate and severe disability were mostly married; however a higher proportion of widowed individuals was observed in these groups compared to no and mild disability; this is most likely associated with the higher proportion of older individuals with moderate and severe disability (Figure 8). Figure 8. Distribution of marital status within disability levels 22 Most individuals with moderate and severe disability were out of the workforce in India (moderate: 39%; severe: 48%) and Tajikistan (moderate: 52%; severe: 78%). Conversely, a low proportion of individuals with moderate (4%) and severe (8%) disability were out of the workforce in Lao PDR, although these proportions were higher compared to individuals with no or mild disability (Figure 9). Figure 9. Distribution of employment status within disability levels Most individuals with moderate and severe disability were living in rural areas or in small villages. Across the three countries, a very small proportion of individuals with severe disability reported living in urban areas (Figure 10). Figure 10. Distribution of setting within disability levels 23 While a similar proportion of income quintiles was observed among individuals with moderate disability, most individuals with severe disability were in the poorest group (Figure 11). Figure 11. Distribution of income quintiles within disability levels 4.2 Health An increasing trend in the prevalence of individuals reporting one or more health conditions (Figure 12) and health problems (Figure 13) was observed across the three countries. Among - Health conditions and health problems very common among people with moderate or severe disability: individuals with moderate and severe disability were disproportionately affected by health conditions and health problems, with more than 70% of individuals with severe disability reporting one or more health conditions - Musculoskeletal conditions and mental disorders frequent in individuals with severe disability: musculoskeletal conditions (e.g. back pain and arthritis) and mental disorders (e.g. depression and anxiety) were the most common conditions in persons with severe disability - Lower satisfaction with availability of quality health care in individuals with severe disability: an overall satisfaction above 60% was reported by persons with severe disability in all three countries; however the rate was lower than for other disability levels - Low use of assistive products among individuals with severe disability: more than 70% of individuals with severe disability reported no use of assistive devices in Lao PDR, and more than 50% in India. In Tajikistan this gap was much less pronounced with nearly 35% only of the individuals with severe disability reporting no use of assistive products Key findings 24 persons with severe disability having one or more health conditions, the highest prevalence was reported in Tajikistan (95%) followed by Lao PDR (80%) and India (73%) (Figure 12); among individuals with severe disability reporting health problems, prevalence was similarly higher in Tajikistan (71%) than in India (50%) and Lao PDR (41%) (Figure 13). Figure 12. Prevalence of individuals reporting one or more health conditions, by disability level Figure 13. Prevalence of health problems, by disability level 25 All health conditions disproportionately affected individuals with moderate and severe disability across the three countries. Among individuals with severe disability, mental disorders (depression and anxiety) and musculoskeletal conditions (back pain and arthritis) were very commonly reported. Hypertension (India and Tajikistan), tinnitus (Lao PDR and Tajikistan), heart disease (Tajikistan) and vision loss also showed high occurrence in individuals with severe disability (Figure 14) Figure 15 shows the mean of Gallup’s personal health index (PHI) by country and disability level. This index measures self-perceived health. On average, individuals from Tajikistan (mean PHI: 77) reported better self-perception of health compared to India (mean PHI: 65) and Lao PDR (mean PHI: 65). A decreasing trend in the self-perception of health was observed across disability levels across all three countries. Tajikistan (mean PHI: 44) showed the lowest mean PHI among individuals with severe disability compared to India (mean PHI: 50) and Lao PDR (mean PHI: 52). Although a high proportion of the population (more than 60% in the three countries) were satisfied with the availability of quality health care in their countries, a decreasing trend in the overall satisfaction of the availability of quality health care was observed across disability levels, with a less pronounced difference in Tajikistan (Figure 16). 26 Figure 14. Prevalence of health conditions, by disability level 27 Figure 15. Perception of one’s own health (Personal Health Index), by disability level Figure 16. Overall satisfaction with the availability of quality health care, by disability level A high proportion of individuals with severe disability in India (56%) and Lao PDR (78%) who reported having one or more health conditions did not use assistive devices. This gap was less pronounced in Tajikistan (38%) (Figure 17). Similar trends were observed for the use of assistive devices among individuals with health problems (Figure 18). 28 Figure 17. Prevalence of individuals reporting one or more health conditions and use of assistive devices, by disability level Figure 18. Prevalence of health problems and use of assistive devices, by disability level A low rate of completely unmet need for assistive technology was observed across the three countries among individuals with moderate disability (India: 19%, Lao PDR: 20%, Tajikistan: 16%) and severe disability (India: 21%, Lao PDR: 33%, Tajikistan: 32%); these individuals reported having one or more chronic conditions (Figure 19). Similar trends were observed in individuals with moderate disability (India: 23%, Lao PDR: 31%, Tajikistan: 19%) and severe disability (India: 24%, Lao PDR: 41%, Tajikistan: 40%) who reported health problems (Figure 20). 29 Figure 19. Prevalence of individuals reporting one or more health conditions and completely unmet need of assistive devices, by disability level Figure 20. Prevalence of health problems and completely unmet need of assistive devices, by disability level 30 4.3 Assistive technology A higher prevalence of use of assistive products was observed in individuals with moderate and severe disability levels in India and Lao PDR. A higher prevalence of use of assistive devices among persons with severe disability was observed in Tajikistan (60%) compared to India (39%) and Lao PDR (19%) (Figure 21). Use of assistive products - Few persons with severe disability used assistive products in Lao PDR: a very low proportion of individuals with severe disability used assistive products in Lao PDR (19%) compared to India (39%) and Tajikistan (60%) - Spectacles/glasses were the most commonly used assistive devices - High occurrence of problems with the use of assistive products: among individuals with severe disability who used assistive devices, 23% (India), 16% (Lao PDR) and 20% (Tajikistan) faced problems with their use Partially unmet need of assistive products - High partially unmet need of assistive products among persons with severe disability: among individuals who used assistive products with severe disability, 25% in India, 21% in Lao PDR and 36% in Tajikistan still needed additional devices - The most frequently reported additionally needed devices among persons with severe disability included “spectacles/glasses”, “hearing aids” and “products for memory support” in India; “chair for shower, bath, or toilet”, “hearing aids” and “magnifiers” in Lao PDR; and “pressure relief cushions” and “chair for shower, bath or toilet” in Tajikistan Completely unmet need of assistive products - Completely unmet need of assistive products common in persons with severe disability: among individuals with severe disability who did not use assistive devices, 18% in India, 30% in Lao PDR, and 29% in Tajikistan needed such products - Spectacles/glasses were frequently needed among individuals with severe disability who did not use any product - The main reasons for not having the assistive products for persons with severe disability included: “products are not comfortable” in India; “cannot afford the cost” in Lao PDR; and “available products are not helpful” in Tajikistan. Key findings 31 Figure 21. Prevalence of individuals using assistive products, by disability level “Spectacles/glasses” were by far the most frequently used assistive product in all countries across all disability levels, with higher frequency observed among individuals with moderate disability. Other frequently used products included “products for memory support”, “pressure relief cushions”, and “canes or walking sticks” (India and Tajikistan); and “communication boards, books or cards” (Lao PDR and Tajikistan) (Figure 22). The prevalence of individuals facing problems with use of assistive products increased across disability levels in both Lao PDR and Tajikistan; no difference across disability levels was observed in India. The prevalence of individuals with severe disability facing problems with use of assistive devices was similar across the three countries (India: 23%, Lao PDR: 16%, Tajikistan: 20%) (Figure 23). The problems most frequently reported included “not comfortable”, “need help from another person to use it”, and “not the right size” (India); “need maintenance or replacements that are not available”, “not the right size” and “broken” (Lao PDR); and “not helpful”, “not the right size”, “need help from another person to use it” and “complicated to use” (Tajikistan) (Figure 24). The need of assistive products among individuals who already used them (partially unmet need) increased across disability levels in India and Tajikistan, while in Lao PDR no difference was 32 observed. Among individuals with severe disability, partially unmet need of assistive devices was higher in Tajikistan compared to India and Lao PDR (Figure 25). Figure 22. Assistive products used, by disability level 33 Figure 23. Prevalence of individuals facing problems with use of assistive products, by disability level Figure 24. Problems faced with use of assistive products, by disability level 34 Figure 25. Partially unmet need of assistive products, by disability level The products most commonly reported as additionally needed among those who already used products included “spectacles/glasses”, “hearing aids” and “products for memory support” (India); “chair for shower, bath, or toilet”, “hearing aids” and “magnifiers” (Lao PDR); “pressure relief cushions”, “chair for shower, bath, or toilet” and “electric wheelchair” (Tajikistan) (Figure 26). 35 Figure 26. Assistive products additionally needed, by disability level Completely unmet need of assistive products was mostly reported by individuals with severe disability. A higher rate of completely unmet need of assistive devices was observed in Lao PDR and Tajikistan compared to India (Figure 27). Across all three countries, “spectacles/glasses” was among the products most frequently reported as needed by those who did not already use products. Also frequently reported as being needed were “pressure relief cushions” and “canes or walking sticks” (India); “magnifier”, “products for memory support” and “canes or walking sticks” (Lao PDR); and “pressure relief cushion” and “chair for shower, bath or toilet” (Tajikistan) (Figure 28). The most commonly reported reasons for not having assistive products included “cannot afford the costs”, “do not know where to get the product” and “no knowledge about the product” (India); “need assistance to use the product, but assistance is not available”, “did not know where to get the product”, “cannot afford the costs”, and “unavailable product in the area” (Lao PDR); 36 and “no one is available to show [the respondent] how to use the product” and “the family does not want [the respondent] to use the product” (Tajikistan) (Figure 29). Figure 27. Completely unmet need of assistive technology, by disability level Figure 28. Assistive products needed (among those who do not already use assistive products), by disability level 37 Figure 29. Reasons for not having the assistive devices needed, by disability level 38 4.4 Aspects of physical environment For all aspects of the physical environment investigated, an increasing rate of persons finding these hindering or very hindering was observed with increased severity of disability. For persons with severe disability, transportation was the most hindering aspect of the environment in India and Lao PDR; in Tajikistan, places for socializing was reported as the most hindering aspect (Figure 30). Figure 30. Prevalence of persons reporting that aspects of physical environment are hindering or very hindering by disability level Key findings - The most hindering aspects of the environment were reported as transportation in India and Lao PDR; and places for socializing in Tajikistan. - A reduced overall satisfaction with housing was reported in India; and roads and highways in Lao PDR and Tajikistan. 39 No difference in the mean overall satisfaction with life in a community (Gallup’s community attachment index) was observed across disability levels in India and Lao PDR. This information was not collected in Tajikistan (Figure 31). Figure 31. Overall satisfaction with life in a community (Gallup’s community attachment index), by disability level A decrease in the overall satisfaction with housing, the educational system, roads and highways and public transport was observed across disability levels; a similar prevalence across disability levels was observed in the three countries for quality of water and quality of air. Among persons with severe disability, lower satisfaction for housing was observed in India, and for roads and highways in Lao PDR and Tajikistan (Figure 32). 40 Figure 32. Proportion of persons satisfied with physical aspects of the environment, by disability level 41 4.5 Aspects of social environment The overall community’s focus on the welfare of its children (Gallup’s youth development index) was high across the three countries and tended to decrease in individuals with moderate and severe disability; larger disparities were observed in India and Tajikistan (Figure 33). Figure 33. Community’s focus on the welfare of its children (Gallup’s youth development index), by disability level Social support and opportunities to make friends in the area lived (Gallup’s social life index) decreased by disability severity, with more pronounced differences observed in India (Figure 34). Key findings - Lower community focus on the welfare of its children was observed among persons with severe disability in India and Tajikistan. - Less social support and opportunities to make friends was observed among individuals with severe disability in India and Tajikistan. - Lower inclination to volunteer one’s own time and assistance to others was observed in persons with severe disability in Tajikistan. - No difference was observed in the prevalence of assault across disability levels in the three countries. 42 Figure 34. Social support and opportunities to make friends in the area lived (Gallup’s social life index), by disability level A low inclination to volunteer one’s own time and assistance to others (Gallup’s civic engagement index) was observed in all three countries across all disability levels, with a slightly lower mean for individuals with severe disability in Tajikistan (Figure 35).Figure 35. Inclination to volunteer one’s own time and assistance to others (Gallup’s civic engagement index), by disability level Individuals with moderate disability in India, and severe disability in India and Lao PDR showed lower acceptance of people from different racial, ethnic or cultural groups (Gallup’s diversity index). This index was not measured in Tajikistan (Figure 36). 43 Figure 36. Acceptance of people from different racial, ethnic or cultural groups (Gallup’s diversity index), by disability level No statistical difference in the prevalence of assault was observed across disability levels in the three countries (Figure 37). Figure 37. Prevalence of assault, by disability level 44 4.6 Political situation The security levels (Gallup’s law and order index) were high across all disability levels in the three countries, with slightly lower levels observed in individuals with severe disability (Figure 38). Figure 38. Security levels (Gallup’s law and order index), by disability level In India, the confidence of citizens in military, judicial and government institutions and honesty in elections (Gallup’s national institutions index) was slightly lower among individuals with moderate and severe disability. This index was not measured in Lao PDR and Tajikistan (Figure 39). Key findings - High security levels were observed in the populations, with slightly lower levels in individuals with severe disability. - Confidence of citizens in military, judicial and government institutions, and honesty in elections were slightly lower among individuals with moderate and severe disability in India. - Perception of corruption in business and government was high in India. 45 Figure 39. Citizen’s confidence in military, judicial and government institutions, and honesty in elections (Gallup’s national institutions index), by disability level Perception of corruption in business and government (Gallup’s corruption index) was high and similar across disability levels in India. This index was not measured in Lao PDR and Tajikistan (Figure 40). Figure 40. Corruption perception in business and government (Gallup’s corruption index), by disability level 46 4.7 Economic situation Remarkably higher poverty levels (Gallup’s food and shelter index) were observed in individuals with severe disability across the three countries, with lower mean food and shelter index observed in Lao PDR compared to India and Tajikistan (Figure 41). Figure 41. Poverty levels (Gallup’s food and shelter index), by disability level Community efforts to provide economic opportunities (Gallup’s job climate index) were lower in India compared to Lao PDR and Tajikistan. Lower mean index was observed for moderate and severe disability levels across all three countries (Figure 42). Key findings - Remarkably higher poverty levels observed in persons with severe disability: a high number of individuals with severe disability reported struggling to afford food and shelter during the past year - Worse attitudes were observed towards a community’s efforts to provide economic opportunities in persons with moderate and severe disability. - Worse personal and community’s economic situation was observed in persons with moderate and severe disability. - Lower access to telephone and internet was observed in persons with severe disability. 47 Figure 42. Community’s efforts to provide economic opportunities (Gallup’s job climate index), by disability level The economic situation of individuals and the community (Gallup’s financial life index) were rated higher in Tajikistan compared to India and Lao PDR. Lower mean index was observed for moderate and severe disability levels across all three countries (Figure 43). Figure 43. Personal and community’s economic situation (Gallup’s financial life index), by disability level Access to telephone and internet for personal use (Gallup’s communication access index) was similar across the three countries. Lower mean index was observed for persons with severe disability (Figure 44). 48 Figure 44. Access to telephone and internet for personal use (Gallup’s communication access index), by disability level 49 4.8 Well-being Approximately 10% of individuals with severe disability reported thriving across the three countries. A decreasing trend in the prevalence of people thriving across disability levels was observed in Lao PDR and Tajikistan; no difference was found in India (Figure 45). Figure 45. Prevalence of persons reporting thriving, by disability level Real-time positive experiences (Figure 46) and negative experiences (Figure 47) were similar across all three countries, with lower mean index in individuals with moderate and severe disability. Key findings - Few persons with severe disability reported thriving: approximately 10% of individuals with severe disability reported thriving across the three countries - Low positive experiences and high negative experiences were reported in persons with moderate and severe disability. - Low optimism was reported in persons with moderate and severe disability. 50 Lower mean optimism (Gallup’s optimism index) was observed in India compared to Lao PDR and Tajikistan across all disability levels. Individuals with moderate and severe disability levels showed lowest mean optimism index (Figure 48). Figure 46. Real-time positive experiences (Gallup’s positive experience index), by disability level Figure 47. Real-time negative experiences (Gallup’s negative experience index), by disability level 51 Figure 48. Positive attitudes about the future (Gallup’s optimism index), by disability level 52 5 Policy implications A high prevalence of disability was observed across the three countries, with persons with higher levels of disability showing worse socioeconomic, health, environment and well-being outcomes. The findings presented in this section could be considered by policy-makers in India, Lao PDR and Tajikistan to ensure that persons with severe disability participate in society on an equal basis with others. Public policies addressing different disabilities are needed in all three countries. Very different disability distributions were observed across the three countries, probably driven by differences in socioeconomic, health conditions, environment and well-being. For example, very high levels of moderate and severe disability were observed in Lao PDR – far higher than the world average disability prevalence estimated in the World report on disability (15%) (3). This highlights a need to target the group of persons with moderate disability in a timely manner to prevent progression to severe disability, and to provide appropriate interventions, accommodations and health care for persons with severe disability. India and Tajikistan, with their higher proportions of people with no, or mild levels, of disability, may wish to implement policies that target these groups, in order to prevent progression to moderate or severe disability. Women need special attention. Women are disproportionately affected by severe disability in India and Tajikistan, indicating that gender-specific consideration is needed by policy-makers in these countries. Adults in the 30–64 age range similarly need special attention. More than half of those with high levels of disability were adults in this age group, surpassing the proportion of older (i.e., aged ≥65 years) adults. This finding indicates that most of those with severe disability were of working age, which could impact the economies of the three countries. Specific policies to provide equal opportunities for education and employment for people with disability are needed so that these individuals can continue to be economically productive for as long as possible. 53 Attention needs to be paid to the economic situation of people with disability. Individuals with high levels of disability had remarkably higher poverty levels. This was most likely driven by their lower educational achievements; lower economic participation; worse community efforts to provide economic opportunities; worse personal and community’s economic situation; and worse access to telephone and internet for personal use. Inclusive policies are required to reduce barriers that prevent people with severe disability from participating equally in education, employment and social services. Persons with high levels of disability were disproportionately affected by health conditions and health problems. By definition, persons with disability were those who experienced health conditions or impairments. However, the results showed that persons with disability remained disproportionately affected by health problems that could be prevented or mitigated. Of 4 individuals with severe disability, 3 reported one or more health conditions, and more than 40% of persons with severe disability reported health problems that prevented the individual from doing things that others of the same age could do. All health conditions investigated were more frequently found among persons with severe disability, with musculoskeletal conditions and mental disorders being the most frequent. A worse self-perception of health was reported by individuals with severe disability. The three countries need to work towards developing interventions targeting people with severe disability and chronic conditions to reduce inequalities in health and meet the specific needs of this group. Quality health care should be more available for people with disability. Fewer individuals with severe disability were satisfied with availability of health care. This finding highlights the need to provide accessible and inclusive health care to persons with severe disability. Attention needs to be paid to the availability of assistive products for people with disability. Of individuals with severe disability, 2 out of 5 (India); 1 out of 5 (Lao PDR); and 3 out 5 (Tajikistan) used assistive devices, with spectacles/glasses being the most frequently used product. High levels of unmet need for products among people with severe disability were observed. The findings in this report point to the need to improve the provision of assistive products, which could be a strategy to reduce the severity of disability in the population. 54 Persons with higher levels of disability faced large disadvantages due to barriers in their physical and social environments. In particular, barriers were reported in places for socializing and transportation that should be addressed. Many people with severe disability were less satisfied with housing and roads and highways; many expressed that their communities had a lower focus on the welfare of their children; and many reported having lower social support and opportunities to make friends in their area. Universal policies should address the need for barrier- free public transportation and barrier-free public places for socializing in order to improve participation in society for all. Attention also needs to the paid to the well-being of people with disability. Only 1 in 10 individuals with severe disability considered themselves as thriving. Persons with moderate and severe disability experienced worse well-being and were less optimistic about their future. This is likely due in part to the problems reported in other areas such as health care, work, education, community and social participation. It is important to reduce these barriers to societal participation and to provide inclusive and accessible health care and support services in order to improve the well-being of people with disability. 55 6 References 1. World Health Organization. WHO | World report on disability. Geneva: World Health Organization; 2011 (available at: http://www.who.int/disabilities/world_report/2011/report/en/ , accessed 12 February 2020). 2. Gallup Inc. World Health Organization Disability Survey. London; 2017. https://www.gallup.com/analytics/232838/world-poll.aspx. 3. World Health Organization. International Classification of Functioning, Disability and Health: ICF. 2001 (available at: http://www.who.int/classifications/icf/en/ , accessed 12 February 2020). 56 7 Annexes 7.1 Annex 1. Overview of variables Table 1. Overview of the variables presented in the report Domain Source Variable Name Definition Response categories Demographic characteristics WHO MDS/ Gallup Gender Weighted proportion of sex • Man • Woman WHO MDS/ Gallup Age group Weighted proportion of age groups • 15–17 years • 18–19 years • 30–49 years • 50–64 years • 65–98 years • ³99 years Gallup Education level Weighted proportion of education level • Elementary or less: completed elementary education or less (up to 8 years of basic education) • Secondary: completed some secondary education up to 3 years tertiary education (9– 15 years of education) • Tertiary: completed 4 years of education beyond “high school” and/or received a four-year college degree • Elementary or less • Secondary • Tertiary Gallup Marital status Weighted proportion of marital status • Single/never married • Married/domestic partner • Separated/ divorced • Widowed Gallup Employment status Weighted proportion of employment status • Employed full time for an employer: employed by an employer and works at least 30 hours/week • Employed full time for self: self-employed and works 30 hours/week • Employed full time for an employer • Employed full time for self • Employed part time, do not want full time • Employed part time, want full time 57 • Employed part time, do not want full time: works for employer or for self and do not work more than 30 hours/week because they do not want to • Employed part time, want full time: works for employer or for self and do not work more than 30 hours/week, but they would like to • Unemployed: not employed in the last 7 days and is actively searching for a job in the last 4 weeks and is able to begin work in the last 4 weeks • Out of workforce: not employed in the last 7 days, is not looking for work and/or is not available to start work • Unemployed • Out of workforce Gallup Setting Weighted proportion of setting • Rural/farm • Small town/village • Large city • Suburb of large city Gallup Religion Weighted proportion of religion • Christian • Islam • Hinduism • Buddhism • Judaism • Secular/-religious • Other Gallup Income quintiles Per capita income quintiles: quintiles of per capita annual income (annual household income in International Dollars divided by the number of individuals living in the household) • Poorest 20% • Second 20% • Middle 20% • Fourth 20% • Richest 20% Disability and Capacity WHO MDS Prevalence of disability Weighted proportion of individuals with no, mild, moderate and severe disability • No • Mild • Moderate • Severe WHO MDS Prevalence of capacity levels Weighted proportion of individuals with no, mild, • No • Mild • Moderate 58 moderate and severe difficulties in capacity • Severe Health WHO MDS Prevalence of individuals reporting one or more health conditions Weighted proportion of individuals reporting one or more health conditions • No reported health conditions • ³ 1 health conditions WHO MDS Prevalence of individuals reporting two or more health conditions Weighted proportion of individuals reporting two or more health conditions • £ 1 health conditions • ³ 2 health conditions Gallup Prevalence of health problems Weighted proportion of individuals reporting health problems that prevent the individual from doing things that people of the same age do • Yes • No WHO MDS Prevalence of vision loss Weighted proportion of individuals reporting vision loss • Yes • No WHO MDS Prevalence of hearing loss Weighted proportion of individuals reporting hearing loss • Yes • No WHO MDS Prevalence of hypertension Weighted proportion of individuals reporting high blood pressure/ hypertension • Yes • No WHO MDS Prevalence of heart disease Weighted proportion of individuals reporting heart disease, coronary disease, or heart attack • Yes • No WHO MDS Prevalence of stroke Weighted proportion of individuals reporting stroke • Yes • No WHO MDS Prevalence of diabetes Weighted proportion of individuals reporting diabetes • Yes • No WHO MDS Prevalence of arthritis/arthrosis Weighted proportion of individuals reporting arthritis or arthrosis • Yes • No WHO MDS Prevalence of bronchitis/ emphysema Weighted proportion of individuals reporting chronic bronchitis or emphysema • Yes • No WHO MDS Prevalence of asthma/allergy Weighted proportion of individuals reporting asthma or allergic respiratory disease • Yes • No WHO MDS Prevalence of back pain Weighted proportion of individuals reporting back pain • Yes • No WHO MDS Prevalence of depression Weighted proportion of individuals reporting depression • Yes 59 • No WHO MDS Prevalence of anxiety Weighted proportion of individuals reporting anxiety • Yes • No WHO MDS Prevalence of amputation Weighted proportion of individuals reporting amputation • Yes • No WHO MDS Prevalence of trauma/injury Weighted proportion of individuals reporting trauma from an accident or event that resulted in bodily injury • Yes • No WHO MDS Prevalence of tinnitus Weighted proportion of individuals reporting tinnitus • Yes • No Gallup Prevalence of satisfaction with the availability of quality health care in the city or area one lives Weighted proportion of individuals satisfied with availability of quality health care in the city or area one lives • Satisfied • Dissatisfied Assistive technology WHO MDS Prevalence of individuals using assistive products Weighted proportion of individuals using assistive products • Yes • No WHO MDS Assistive products used Number of individuals using specific assistive products • Canes or walking sticks • Chair for shower, bath, or toilet • Communication boards, books or cards • Crutches • Electric wheelchair • Hearing aids • Incontinence products • Magnifier • Manual wheelchair • Orthosis or brace • Pressure relief cushions • Products for memory support • Prosthesis/ artificial leg • Spectacles/glasses • Tricycle • Walking frame or rollator 60 • White cane for partial or complete blindness WHO MDS Prevalence of individuals facing problems with use of assistive products Weighted proportion of individuals facing problems with use of assistive products • Yes • No WHO MDS Problems faced with use of assistive products Number of individuals reporting specific problems with use of assistive products • Broken • Complicated to use • Feel like people treat you difference when you use it • Find it embarrassing • Need help from another person to use it • Need maintenance or replacements that are not available • No one showed how to use it • Not comfortable • Not helpful • Not safe • Not suitable for your home or surroundings • Not the right size • Self-made, temporary solution • Share it with another people • Other problems WHO MDS Prevalence of partially unmet need of assistive products Weighted prevalence of partially unmet need of assistive products (additional need among persons who use assistive products) • Yes • No WHO MDS Assistive products additionally needed Number of individuals reporting the need of more products than they already have • Canes or walking sticks • Chair for shower, bath, or toilet 61 • Communication boards, books or cards • Crutches • Electric wheelchair • Hearing aids • Incontinence products • Magnifier • Manual wheelchair • Orthosis or brace • Pressure relief cushions • Products for memory support • Prosthesis/ artificial leg • Spectacles/glasses • Tricycle • Walking frame or rollator • White cane for partial or complete blindness WHO MDS Prevalence of completely unmet need of assistive products Weighted prevalence of completely unmet need of assistive products (need of assistive products among persons who do not use them) • Yes • No WHO MDS Assistive products needed by persons who do not use them Number of individuals reporting the need of assistive products among those who do not use them • Canes or walking sticks • Chair for shower, bath, or toilet • Communication boards, books or cards • Crutches • Electric wheelchair • Hearing aids • Incontinence products • Magnifier • Manual wheelchair • Orthosis or brace • Pressure relief cushions 62 • Products for memory support • Prosthesis/ artificial leg • Spectacles/glasses • Tricycle • Walking frame or rollator • White cane for partial or complete blindness WHO MDS Reasons for not having assistive products Number of individuals reporting the reasons for not having assistive products • Available products are not helpful • Available products are not safe • Available products not suitable for your home or surroundings • Cannot afford the cost • Did not get approval needed • Did not know where to get the product • Need assistance to use the product, but assistance is not available • No knowledge about the product • No one is available to show how to use the product • People would treat you differently if you had the product • Products are not comfortable • Products are too complicated to use 63 • Suitable transportation is not available to get the product • Unavailable product in the area • You thought you would not be eligible to get the product • You would feel embarrassed if you had the product • Your family does not want you to use the product • Other reason Physical environment WHO MDS Prevalence of persons reporting that selected aspects of the physical environment are hindering or very hindering Weighted proportion of persons reporting that selected aspects of the physical environment are hindering or very hindering • Places for socializing and engaging in community activities • Shops, banks, post office • Transportation • Dwelling Gallup Prevalence of persons satisfied with selected physical aspects of the environment Weighted proportion of persons satisfied with selected physical aspects of the environment • Public transport • Roads and highways • Educational system • Quality of air • Quality of water • Housing Social environment Gallup Prevalence of assault Weighted proportion of individuals who reported being assaulted or mugged in the past 12 months • Yes • No Well-being Gallup Prevalence of individuals thriving Weighted proportion of individuals who rate their current lives a “7” or higher AND their future an “8” or higher in a self-anchoring thriving scale, where 0 indicates the worst possible life and 10 the best possible life • Yes • No 64 Table 2. Overview of Gallup indexes Index Definition Gallup questions Index construction Personal health index Weighted mean perception of own’s health (high mean index indicates better self-perceived health) • Do you have any health problems that prevent you from doing any of the things people your age normally can do? (WP23) • Now, please think about yesterday, from the morning until the end of the day. Think about where you were, what you were doing, who you were with, and how you felt. Did you feel well-rested yesterday? (WP60) • Did you experience the following feelings during a lot of the day yesterday? How about physical pain? (WP68) • Did you experience the following feelings during a lot of the day yesterday? How about worry? (WP69) • Did you experience the following feelings during a lot of the day yesterday? How about sadness? (WP70) All items are recoded so that favourable answers are scored as a “1” and all other answers (including don’t know and refused) are assigned a score of “0” for each individual. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. Respondents must have answered at least three questions for an individual index to be calculated. A record’s final index score is the mean of valid items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. Community attachment index Weighted mean satisfaction with the city or area where the respondent lives and the likelihood to move away or recommend that city or area to a friend (high mean index indicates high satisfaction) • Are you satisfied or dissatisfied with the city or area where you live? (WP83) • In the next 12 months, are you likely or unlikely to move away from the city or area where you live? (WP85) • Would you recommend the city or area where you live to a friend or associate as a place to live, or not? (WP86) The three items are recoded so that favourable answers are scored as a “1” and all other answers (including don’t know or refused) are a “0” for each individual. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. An individual record has an index calculated if it has two valid scores (0 or 1). The record’s final score is the mean of valid items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. 65 Youth development index Weighted mean of a community’s focus on the welfare of its children (high mean index indicates high focus) • In the city or area where you live, are you satisfied or dissatisfied with the educational system or the schools? (WP93) • Do you believe that children in (country) are treated with respect and dignity, or not? (WP129) • Do most children in (country) have the opportunity to learn and grow every day, or not? (WP130) The three items are recoded so that positive answers are scored as a “1” and all other answers (including don’t know and refused) are assigned a score of “0” for each individual. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. An individual record has an index calculated if it has valid scores for all items. A record’s final index score is the mean of valid items multiplied by 100. The final country- level index score is the mean of all individual records for which an index score was calculated. Social life index Weighted mean of social support structure and opportunities to make friends in the city or area where he or she lives (high mean index indicates high social support) • If you were in trouble, do you have relatives or friends you can count on to help you whenever you need them, or not? (WP27) • In the city or area where you live, are you satisfied or dissatisfied with the opportunities to meet people and make friends? (WP10248) The two items are recoded so that positive answers are scored as a “1” and all other answers (including don’t know and refused) are assigned a score of “0” for each individual. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. An individual record has an index calculated if it has valid scores for both questions. A record’s final index score is the mean of valid items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. Civic engagement index Weighted mean of the respondent’s commitment to the community where he or she lives (high mean index indicates high commitment) • Have you done any of the following in the past month? How about donated money to a charity? (WP108) • Have you done any of the following in the past month? How about volunteered your time to an organization? (WP109) • Have you done any of the following in the past month? How about helped a stranger or someone you didn’t know who needed help? (WP110) The three items are recoded so that positive (or favourable) answers are scored as a “1” and all other answers (including don’t know and refused) are assigned a score of “0” for each individual. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. An individual record has an index calculated if it has scores for at least two items (0 or 1). A record’s final index score is the mean of valid items multiplied by 100. The final country-level index score is the mean of all individual records for 66 which an index score was calculated. Diversity index Weighted mean of community’s acceptance of people from different racial, ethnic or cultural groups (high mean index indicates high acceptance) • Is the city or area where you live a good place or not a good place to live for racial and ethnic minorities? (WP103) • Is the city or areas where you live a good place or not a good place to live for gay or lesbian people? (WP105) • Is the city or area where you live a good place or not a good place to live for immigrants from other countries? (WP106) The four items are recoded so that positive answers are scored as a “1” and all other answers (including don’t know and refused) are assigned a score of “0” for each individual. If a record has no answer for an item then that item is not eligible for inclusion in the calculations. An individual record has an index calculated if it has valid scores for at least three items. A record’s final index score is the mean of valid items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. Law and order index Weighted mean security levels that respondents report (high mean index indicates high security levels) • In the city or area where you live, do you have confidence in the local police force? (WP112) • Do you feel safe walking alone at night in the city or area where you live? (WP113) • Within the last 12 months, have you had money or property stolen from you or another household member? (WP117) • Within the past 12 months, have you been assaulted or mugged? (WP118) The four items are coded so that positive (or favourable) answers are scored a “1” and all other answers (including don’t know and refused) are assigned a score of “0” for each individual. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. An individual record has an index calculated if it has scores for two out of four items. A record’s final index score is the mean of valid items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. National institutions index Weighted mean citizens’ confidence in key institutions prominent in a country’s leadership: the military, the judicial system, the national government and the honesty of elections (high mean index indicates high confidence) • Do you have confidence in each of the following, or not? How about the military? (WP137) • Do you have confidence in each of the following, or not? How about the judicial system and courts? (WP138) • Do you have confidence in each of the following, or not? The four items are recoded so that positive answers are scored as a “1” and all other answers (including don’t know and refused) are assigned a score of “0” for each individual. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. An individual record has an index calculated if it has valid scores for at least two of the four items. A record’s final index score is the mean of valid items multiplied by 100. The final country-level index 67 How about the national government? (WP139) • Do you have confidence in each of the following, or not? How about the honesty of elections? (WP144) score is the mean of all individual records for which an index score was calculated. Corruption index Weighted mean perceptions in a community about the level of corruption in business and government (high mean index indicates high corruption perception) • Is corruption widespread within businesses located in (country), or not? (WP145) • Is corruption widespread throughout the government in (country), or not? (WP146) The two items are recoded so that affirmative answers (i.e. “corrupt”) are scored as “1” and all other answers (including don’t know and refused) are assigned a score of “0” for each respondent. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. An individual record has an index calculated if it has valid scores for both items. A record’s final index score is the mean of valid items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. Food and shelter index Weighted mean ability people have to meet basic needs for food and shelter (high mean index indicates few respondents are struggling to afford food and shelter in the past year) • Have there been times in the past 12 months when you did not have enough money to buy food that you or your family needed? (WP40) • Have there been times in the past 12 months when you did not have enough money to provide adequate shelter or housing for you and your family? (WP43) The two items are recoded so that positive (or favourable) answers are scored a “1” and all other answers (including don’t know and refused) are assigned a score of “0” for each individual. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. An individual record has an index calculated if it has valid scores for both questions. A record’s final index score is the mean of valid items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. Job climate index Weighted mean attitudes about a community’s efforts to provide economic opportunities. (high mean index indicates more positive attitudes). • Right now, do you think that economic conditions in the city or area where you live, as a whole, are getting better or getting worse? (WP88) • Thinking about the job situation in the city or area where you live today, would you say that it is now a good The two items are recoded so that positive answers are scored as a “1” and all other answers, including don’t know and refused, are assigned a score of “0” for each individual. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. An individual record has an index 68 time or a bad time to find a job? (WP89) calculated if it has valid scores for both questions. A record’s final index score is the mean of valid items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. Financial life index Weighted mean personal economic situation and the economics of the community where they live (high mean index indicates high economic situation) • Which one of these phrases comes closest to your own feelings about your household’s income these days: living comfortably on present income, getting by on present income, finding it difficult on present income, or finding it very difficult on present income? (WP2319) • Are you satisfied or dissatisfied with your standard of living, all the things you can buy and do? (WP30) • Right now, do you feel your standard of living is getting better or getting worse? (WP31) • Right now, do you think that economic conditions in the city or area where you live, as a whole, are getting better or getting worse? (WP88) For WP2319, respondents who say they are “living comfortably on present income” are recoded as “1,” and all other answers are recoded as a “0.” The remaining three items are recoded so that positive answers are scored as a “1” and all other answers (including don’t know and refused) are assigned a score of “0” for each respondent. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. An individual record has an index calculated if it has valid scores for WP2319 and valid scores from at least two of the other three index questions. A record’s final index score is the average of the mean for responses to WP2319 and the mean of the three other items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. Communication access index Weighted mean access to telephone and internet for personal use (high mean index indicates high access) • Do you have a landline telephone in your home that you use to make and receive personal calls? (WP15191) • Do you have a mobile phone that you use to make and receive personal calls? (WP17624) • Do you have access to the internet in any way, whether on a mobile phone, a computer, or some other device? (WP16056) The first two questions (landline telephone and mobile phone) are used to determine whether a respondent has a phone and are used to create the phone component of the index. If respondents answer “yes” to either question, they are assigned a score of “1” for the phone component and a “0” if they do not have a phone. For the remaining question, positive answers are scored as a “1” and all other answers (including don’t know and refused) are assigned a score of “0”. An individual record 69 has an index calculated if it has valid scores for both components. A record’s final index score is the mean of items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. Positive experience index Weighted mean of respondents’ experienced well- being on the day before the survey (high mean index indicates high positive well-being) • Did you feel well-rested yesterday? (WP60) • Were you treated with respect all day yesterday? (WP61) • Did you smile or laugh a lot yesterday? (WP63) • Did you learn or do something interesting yesterday? (WP65) • Did you experience the following feelings during a lot of the day yesterday? How about enjoyment? (WP67) The five items are recoded so that positive answers are scored as a “1” and all other answers (including don’t know and refused) are scored as a “0” for each individual. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. An individual record has an index calculated if it has at least four out of five valid scores (0 or 1). The record’s final score is the mean of valid items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. Negative experience index Weighted mean of respondents’ experienced well- being on the day before the survey (high mean index indicates high negative well-being) • Did you experience the following feelings during a lot of the day yesterday? How about physical pain? (WP68) • Did you experience the following feelings during a lot of the day yesterday? How about worry? (WP69) • Did you experience the following feelings during a lot of the day yesterday? How about sadness? (WP70) • Did you experience the following feelings during a lot of the day yesterday? How about stress? (WP71) • Did you experience the following feelings during a lot The five items are recoded so that affirmative answers are scored as a “1” and all other answers (including don’t know or refused) are a “0” for each individual. If a record has no answer for an item, then that item is not eligible for inclusion in the calculations. An individual record has an index calculated if it has at least four out of five valid scores (0 or 1). The record’s final score is the mean of valid items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. 70 of the day yesterday? How about anger? (WP74) Optimism index Weighted mean positive attitudes about the future (high mean index indicates high optimism) • Right now, do you feel your standard of living is getting better or getting worse? (WP31) • Right now, do you think that economic conditions in the city or area where you live, as a whole, are getting better or getting worse? (WP88) • Please imagine a ladder, with steps numbered from 0 at the bottom to 10 at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you. Just your best guess, on which step do you think you will stand in the future, say about five years from now? (WP18) The first two items are recoded so that favourable answers are scored as a “1” and all other answers (including don’t know and refused) are assigned a score of “0”. If a record has no answer for an item then that item is not eligible for inclusion in the calculations. The score on the ladder question (ranging from 0 to 10) is divided by 10 and the respondent is assigned a score ranging from 0 to 1. An individual record has an index calculated if it has valid scores for at least two of the three items. A record’s final index score is the mean of valid items multiplied by 100. The final country-level index score is the mean of all individual records for which an index score was calculated. 71 7.2 Annex 2. Statistical analysis used in the Brief MDS In the Brief MDS, two scales are relevant: disability and capacity. Disability and capacity are defined as universal phenomena characterized by a continuum ranging from low to high levels. This definition requires the use of metric scales to assess disability and capacity. As recommended by the World report on disability, two scales with metric properties were built: (i) a capacity scale, based on the capacity questions; and (ii) a disability scale, based on disability (i.e. functioning) questions. Figure 1 shows the process for building these scales. Figure 1. Process for building the disability and capacity scales in the Brief MDS The polytomous Rasch model, also known as the partial credit model (PCM), was used in the Brief MDS to develop the capacity and disability scales with metrical properties. The Rasch model is an item response theory (IRT) model suitable to transform ordered categorical (polytomous) items into an equal-interval latent scale. Both persons and items can be located on the scales (continuous latent constructs). With the Rasch model, for each respondent, the person’s ability, i.e. the location of the person in each continuum (capacity and performance scales), is calculated and for each item and the item difficulty, i.e. the location of the item in each scale, is estimated. Additionally, item thresholds are estimated for each item, indicating the locations on the latent scale where the item best discriminates between persons. The equality of intervals in each scale is obtained by using a linear transformation to the person’s 72 ability and item difficulty, resulting in a scale ranging from 0 (lowest level of problems or difficulties) to 100 (highest levels of problems or difficulties). The model assumptions – item independence, unidimensionality, stochastic ordering, group invariance, and fit to the model – should be checked and, if necessary, remedial measures taken to improve the model (Table 1). Table 1. Assumptions of the Rasch model Assumption Interpretation How it can be checked? How it can be fixed? (Remedial measures) Item independence Reponses from one item should not be strongly related (correlated) to responses in another item. Residual correlation Aggregation of highly correlated items into one “super item” or “testlet”. For example, two highly correlated items, each with 5 response options, could be combined into a testlet by adding up the responses for each person. This testlet would have 9 response options. Unidimensionality All questions measure the same underlying single construct. In the MDS, all items should be measuring the same underlying construct of disability and capacity. Visual inspection of scree plot Splitting items onto multiple scales. Stochastic ordering Thresholds (i.e. boundaries between response options) being in the correct order. Visual inspection of the person-item map Recoding response options in order to create fewer thresholds between items that are more likely to be in order. Group invariance Items behaving similarly for people with different characteristics. Differential item functioning (DIF) Splitting items into subgroups. This assumption is usually violated in the MDS, as persons of different sex and age are expected to experience different levels of disability Fit to the model The fit of items, persons, and the model overall are measured with various fit statistics. • Do items fit the model? Examine item fit (outfit and infit statistics) • Do people fit the model? Examine person fit • How is the model overall? Examine reliability scores, such as person separation index (PSI) For items or persons with poor fit to the model: delete items or persons from the scale. This would be considered a last resort, as it indicates that the created scale does not examine all the items or persons originally intended for measurement.