Do children with disabilities have the same opportunities to play as children without disabilities? Evidence from the Multiple Indicator Cluster Surveys in 38 low and middle-income countries
Authors: Smythe Tracey , Chen Shanquan , Rotenberg Sara , Unger Marianne , Miner Emily , Seghers Frederic , Servili Chiara , Kuper Hannah 
Published: October 2023

AbstractBackgroundPlay is essential for the cognitive, social, and emotional development of all children. Disparities potentially exist in access to play for children with disabilities, and the extent of this inequity is unknown.MethodsData from 212,194 children aged 2-4 years in 38 Low and Middle-Income Countries were collected in the UNICEF supported Multiple Indicator Cluster Survey (2017 – 2020). Disability was assessed by the Washington Group-Child Functioning Module. Logistic regression models were applied to investigate the relationship between disability and play opportunities, controlling for age, sex, and wealth status. Meta-analysis was used to pool the estimates (overall, and disaggregated by sex), with heterogeneity assessed by Cochran’s Q test.FindingsChildren with disabilities have approximately 9% fewer play opportunities than those without disabilities (adjusted RR [aRR] =0.88, 95%CI=0.82–0.93), and this varied across countries. Mongolia and Democratic Republic of São Tomé and Príncipe had the lowest likelihood of play opportunities for children with disabilities ((aRR=0.26,95%CI=0.09-0.75; aRR=0.46, 95%CI=0.23-0.93, respectively). Moreover, children with disabilities are 17% less likely to be provided with opportunities to play with their mothers (aRR=0.83, 95%CI: 0.73–0.93), which is further reduced for girls with disabilities (aRR=0.74, 95% CI:0.60-0.90) compared to their peers without disabilities. The associations varied by impairment type, and children with communication and learning impairments are less likely to have opportunities for play with aRR of 0.69 (95%CI: 0.60-0.79) and 0.78 (95%CI:0.71–0.86), compared to those without disabilities, respectively.InterpretationChildren with disabilities are being left behind in their access to play and this is likely to have negative impacts on their overall development and well-being.FundingHK and TS receive funding from NIHR. The Study was funded by PENDA. SR receives funding from the Rhodes Trust.Evidence before this studyWe searched PubMed and Google Scholar for studies reporting population-representative estimates of children with disabilities’ exposure to play in low-income and middle-income countries (LMICs) published before Feb 7th, 2023. We used the following combination of keywords: “play” AND (“early childhood” OR “preschool” OR “young children”) AND (disability OR disabilities) AND “prevalence”. We found no multi-country studies reporting the prevalence or country-level disparities (within or between countries) for opportunities for play for children with disabilities. We did not identify any studies synthesising or comparing estimates across all dimensions of play or disability, nor did we identify studies reporting population-representative estimates of play for all LMICs. UNICEF has published global reports, which reveal that children with disabilities receive less early stimulation and responsive care and have limited exposure to children’s books and toys compared to children without disabilities, however opportunities for play within the household setting have not been examined in a comprehensive analysis.Added value of this studyTo our knowledge, this is the first study to explore the opportunities for play for children with disabilities compared to those without across multiple countries. Moreover, it provides a large dataset on this topic including 212,194 children aged 2–4 years from 38 low and middle income countries (LMICs), including approximately 6.1% with disabilities (i.e. reporting a lot of difficulty or more in a functional domain). The study has advanced the literature in five substantive ways. First, we highlighted that children with disabilities have fewer opportunities to play, across multiple measures of play and multiple settings. Second, we demonstrated that there are disparities in play opportunities for children with disabilities across countries. Third, we showed that this varied by impairment and was worst for children with learning and communication impairments. Fourth, we showed that there was a discrepancy between girls and boys with disabilities. Finally, our work extends beyond simple description by deploying ratio ratios to provide a quantitative risk assessment. This enables us to identify areas of particular concern and suggest where interventions may be most needed. The ratio ratios shed light on the severity of disparities and pinpoint specific high-risk categories such as particular countries, types of disabilities, or population groups. This analysis is crucial for refining interventions and optimising resource allocation, especially in low- and middle-income countries.Implications of all the available evidenceThe study findings emphasise the importance of including children with disabilities in early child development programmes, and where relevant preschool, which may require modifications to ensure inclusivity. Programmes are needed that specifically target children with learning or communication impairments. This may work best through parent support programmes, as formal preschool or programmes may be lacking in LMICs. Monitoring participation is crucial for children with disabilities. To promote equal opportunities for play at home, in schools, and in other community settings, it is necessary to improve the knowledge and attitudes of parents, teachers, and caregivers, as well as implement policies that address barriers to participation. The findings underscore the urgent need for policies to reflect the inclusion of children with disabilities. Research is needed to establish evidence regarding the importance of promoting play opportunities beyond the home environment, including pre-schools, schools, and community settings. Furthermore, well-designed studies to provide affordable, timely and accessible data on effective strategies for enhancing play for children with disabilities are required. This information will enable programme developers and policy makers to make evidence-based decisions on improving the lives of children with disabilities worldwide.