Introduction
Globally, there are an estimated 240 million children aged 0–17 years with disabilities (UNICEF 2021). Child disability is more common in low- and middle-income countries (LMICs) (UNICEF 2021). Children with disabilities and their families face multiple challenges, including increased poverty, stigma and discrimination, and poorer physical and emotional well-being (Emerson and Hatton 2007; Mitra et al. 2017). Studies have shown that families of children with disabilities spend significant amounts on additional goods and services related to their child’s disability, including specialised healthcare (e.g., physiotherapy), assistive technology, and accessible transport (Mitra et al. 2017). Their capacity to pay for these items may be restricted, as caregivers often reduce their participation in income-generating activities to provide caregiving support (Nugent et al. 2018; WHO 2024). Consequently, children with disabilities and their families are at high risk of poverty (Banks, Kuper and Polack 2017).
According to the International Classification of Functioning, Disability and Health (ICF), disability arises from the interaction between an individual’s health condition and the environmental factors and personal factors around them, such as unmet need for disability-related services and household poverty (WHO 2001). Addressing unmet need for disability-related services is therefore essential to support children’s functioning. It is also crucial from a rights-based perspective to promote equitable participation in society for children with disabilities. The United Nations Convention on the Rights of Persons with Disabilities (CRPD) emphasizes the right to health, education, and social inclusion for children with disabilities (UNGA 2006). Disability-inclusive and accessible healthcare systems must provide specialised health and rehabilitation services such as occupational therapy, physiotherapy, speech and language therapy, and assistive technology, which are crucial for learning, mobility, communication, and daily activities. Assistive technology, in particular, is essential for enabling children with disabilities to participate in education, engage in daily activities, and achieve greater independence (World Health Organization 2016). However, access to assistive technology remains severely limited in LMICs due to high costs, lack of local availability, insufficient trained personnel for assessment and provision, and limited awareness among families and service providers (MacLachlan et al. 2018). Disability-related support is also needed in school, including teachers trained in inclusive education, assistive technology to support learning, and adapted educational resources. Despite international commitments to inclusive education, children with disabilities in LMICs continue to face significant barriers to school participation, including inaccessible infrastructure, lack of teacher training in inclusive pedagogies, insufficient learning materials, and negative attitudes toward disability (Bani Odeh and Lach 2024).
Despite need, access to disability-related services is limited for children with disabilities, especially in LMICs. Unmet need for assistive technology was recently found to range from 25% to 90% in Africa and Asia (WHO and UNICEF 2022). By 2050, the World Health Organization (WHO) projects that 3.5 billion people will require assistive technology, but only 10% will have access. Lack of access to disability-related services negatively impacts children with disabilities’ development, health, education, and future employment, and is a violation of their rights. There have been several initiatives to address this unmet need, including the WHO’s Rehabilitation 2030 Initiative and the AT2030 Programme (World Health Organization 2017; Global Disability Innovation Hub 2025). However, policy reforms, increased funding, and workforce training are still needed to address existing disability-related service gaps, particularly in LMICs (UNGA 2006).
In the Lao People’s Democratic Republic (Lao PDR), approximately 160,000 people aged five years and older have a disability, with a higher prevalence among ethnic minorities and rural populations (LSB 2020). Previous research has demonstrated challenges in developing disability-related services for people with disabilities in Lao PDR, notably for those with intellectual disabilities (Thoresen et al. 2017). Challenges include a lack of infrastructure for disability-related services and stigma towards people with disabilities (Thoresen et al. 2017). Thus, many children with disabilities face critical service gaps, particularly in remote regions such as Xiengkhouang Province (LSB 2020; Thoresen et al. 2017). However, there is a dearth of literature on the situation of children with disabilities in Lao PDR with which to inform action.
In recent years, Lao PDR has developed the National Policy, Strategy and Action Plan on Persons with Disabilities (2020–2030), which makes commitments to promote the rights and well-being of persons with disabilities in line with the CRPD (UN Committee on the Rights of Persons with Disabilities 2022). Additionally, the Disability-Inclusive Rehabilitation Strategy and Action Plan (2018–2025) aims to integrate rehabilitation services across all levels of the healthcare system. However, in a recent report, the United Nations Committee on the Rights of Persons with Disabilities highlights several concerns regarding disability-related services in Lao PDR (UN Committee on the Rights of Persons with Disabilities 2022). The Committee notes the limited implementation of the rehabilitation strategic plan, resulting in a lack of available services and programmes, limited access to assistive technology, and insufficient financial support to increase service provision. The Committee highlighted the lack of support for children with disabilities, particularly children belonging to ethnic minority groups and children with intellectual disabilities. The joint statement by the United Nations Country Team on the progress towards implementation of the CRPD in Lao PDR further notes that rehabilitation is not provided at district level, except at a hospital in Xiengkhouang Province, and there is no specific budget line for assistive technology within Ministry of Health budgets, leaving provision reliant on external funding (UN 2023). In their concluding observations, the Committee on the Rights of Persons with Disabilities notes with concern, the absence of data on the situation of people with disabilities, including children with disabilities.
This study, therefore, aims to examine the extent of unmet need for essential disability-related services among children with disabilities and their predictors. Specifically, we aim to evaluate unmet need across four key areas: (a) healthcare related to disability; (b) assistive technology; (c) assistance for daily tasks; and (d) disability-related support at school. These services were selected as they are common unmet needs for children with disabilities globally, with significant implications on their functioning, participation, and well-being (Cote and Banks 2025). These services are also dominant sources of extra costs for households with children with disabilities (Banks et al. 2025).
Methods
Study design and setting
The data presented in this article were collected as part of the baseline assessment for a non-randomised controlled trial evaluating a cash-plus programme for children with disabilities delivered by United Nations Children’s Fund (UNICEF) and the government of Lao PDR (Banks et al. 2024). The programme consists of a monthly cash transfer, provision of assistive products to those assessed to require one, and a family support programme (including training to caregivers on the child’s disability and financial management). The study is being conducted in five districts of Xiengkhouang Province in Lao PDR, with participants from three districts (Pek, Khoun, Phoukoud) assigned to the intervention group and participants from two districts (Nonghed, Kham) serving as the control group. Data for this analysis were from the trial baseline assessment; no participant had started to receive any component of the intervention, and they were not yet informed whether they would be offered enrolment to the programme.
Study participants and recruitment
Children with disabilities participating in this study were recruited from a list of children eligible for the cash-plus programme, developed by UNICEF. To develop this list, UNICEF provided training to village authorities, often the head of the village, to identify children with disabilities in their village. Identified children under 18 years of age in Pek, Khoun, Phoukoud, and Nonghed were subsequently assessed for disability via parent report using the Washington Group Child Functioning Module (Loeb et al. 2017), by trained personnel from District and Provincial offices of the Ministry of Labour and Social Welfare. Children were classified as having a disability if they reported at least ‘some’ difficulty in at least one of the 8–13 functional domains assessed, depending on their age. Children in Kham District were identified by report from the village authority only. Children identified as having a disability were grouped based on type of difficulty: physical, sensory (hearing or vision), cognitive/learning, speech, and multiple/other.
The eligibility criteria for inclusion in the study were as follows: (1) children residing in the designated study districts of Xiengkhouang Province; (2) children aged 18 years or younger; and (3) children identified as having a disability by UNICEF.
Sample size
The sample size was determined based on the primary trial outcome: improvement in child wellbeing, measured using the Multiple Overlapping Deprivation Analysis (MODA) index (de Neubourg et al. 2013; Li et al. 2023). Based on a requirement to detect a minimum change in score of 0.0344 with 80% power, 5% Type I error rate, and an expected 20% loss to follow-up, the total sample size required was 405 participants (249 in the intervention group, 156 in the control group).
Data collection
Data collection was conducted between May and October 2023. Participants were invited to take part in the study by research staff, either in-person or over the phone. The survey questionnaire was administered by trained data collectors who had completed a five-day training programme covering the study objectives, ethical considerations, interview techniques, and data entry procedures. The questionnaire was piloted with caregivers prior to implementation at the National Rehabilitation Centre, Vientiane Capital, Lao PDR. Questions on need and access to disability-related services for children with disabilities were answered by the child’s primary caregiver. Most data were collected via in-person interviews at the participants’ homes, although some were obtained over the phone when challenging terrain or weather conditions prevented face-to-face visits. Data were collected using Open Data Kit (ODK) software installed on tablets. The questionnaire was available in Lao and Hmong, as the Hmong population is 9% of the total population of Lao PDR, with the majority living in Xiengkhouang Province, the study site (LSB 2015).
Outcome measures
Socio-demographic data were collected for all participants. Data were collected on caregiver perceived knowledge and unmet need for: a) healthcare services related to the child’s disability; b) assistive technology; c) assistance for daily tasks beyond what would be typical for a child without a disability of the same age; and d) disability-related supports for school. Caregivers were first asked if they thought their child needed support under each domain, and if they did, if they had accessed support, and if they were satisfied with the services/products received. Unmet need for each category was defined as not accessing a needed service/product of a satisfactory quality, amongst children for whom a need was reported (i.e., either needing support but not accessing support, or accessing support but support was reported unsatisfactory quality). Caregivers were also asked about their perceived knowledge on the specific types of support their child needed under each service (e.g. knowledge on the specific type of assistive device their child needed) and if they knew how to provide support for their child’s daily life activities. Those responding that they ‘strongly agreed’ or ‘somewhat agreed’ were defined as having ‘good’ perceived knowledge for each knowledge domain. The questions on caregiver perceived knowledge and access to services are provided in Appendix A.
Statistical analysis
Using a Multivariate Regression Model, we explored predictors of unmet need for disability-related services, including child characteristics (age, sex, ethnicity, disability type), caregiver characteristics (sex, perceived knowledge of relevant disability-related services), and household characteristics (poverty). Ethnicity was classified as Lao Tai, Hmong/Lu Mien, other. Disability type was based on UNICEF classifications and grouped into physical, sensory (hearing, vision), cognitive/learning, speech, and multiple/other. Relative poverty was calculated based on whether the household was in the bottom two quintiles of expenditures amongst sampled households. Adjusted risk ratios (aRR) were calculated in StataSE 17 using three separate modified Poisson regressions with robust error variance (Zou 2004) to explore predictors of unmet need for healthcare, assistive technology, and daily support. Unmet need for school support was restricted to children attending school, but as few children were reported to attend school, this variable was excluded from the analysis to identify predictors.
Ethical considerations
This study received ethical approval from the Lao National Health Research Ethics Committee (Approval No. 13/NECHR) and the Research Ethics Committee at the London School of Hygiene & Tropical Medicine (Reference: 28234). Before enrolment, all participants provided written informed consent. Participants did not receive financial compensation for taking part in the survey. They instead received hygiene products, such as soap and detergent, as a token of appreciation for their time. Signed consent forms were stored in locked, secure cabinets at the Lao Tropical and Public Health Institute. Data were stored on a secure and encrypted ODK server hosted by the London School of Hygiene & Tropical Medicine. A master file linking participants’ identifiable information with their unique study identification number was stored in an encrypted file separate from the data files.
Results
Participant characteristics
In total, 405 children with disabilities and their caregivers were recruited to the study (response rate = 94%). Sociodemographic characteristics of the study population are summarised in Table 1. Participants were recruited from five districts: Khoun (27%, n = 109), Nonghed (26%, n = 106), Pek (18%, n = 73), Phoukoud (17%, n = 67), and Kham (12%, n = 50). The majority of children with disabilities were aged between 12–18 years old (46%, n = 185). Lao Tai (47%, n = 191) and Hmong/Lu Mien (45%, n = 184) were the predominant ethnic groups. The majority of children had physical disabilities (37%, n = 148), or multiple/other disabilities (29%, n = 116). Among school-aged children (6+ years), only 55% (n = 182) were enrolled in education. The majority of the sample were male (59%). Boys were more likely to have cognitive/learning disabilities (p < 0.05). There were no significant differences on other traits between boys and girls.
Table 1
Summary sample characteristics.
| VARIABLE | ALL | GIRLS | BOYS | |||
|---|---|---|---|---|---|---|
| N | PERCENT | N | PERCENT | N | PERCENT | |
| Total | 405 | 100% | 168 | 42% | 237 | 59% |
| District | ||||||
| Pek | 73 | 18% | 26 | 16% | 47 | 20% |
| Khoun | 109 | 27% | 48 | 29% | 61 | 26% |
| Phoukoud | 67 | 17% | 30 | 18% | 37 | 16% |
| Nonghed | 106 | 26% | 45 | 27% | 61 | 26% |
| Kham | 50 | 12% | 19 | 11% | 31 | 13% |
| Age | ||||||
| 0–6 | 72 | 18% | 30 | 18% | 42 | 18% |
| 6–12 | 148 | 37% | 59 | 35% | 89 | 38% |
| 12–18 | 185 | 46% | 79 | 47% | 106 | 45% |
| Disability type | ||||||
| Physical | 148 | 37% | 65 | 39% | 83 | 35% |
| Sensory | 54 | 13% | 22 | 13% | 32 | 14% |
| Cognitive/learning | 54 | 13% | 13 | 8% | 41 | 17%* |
| Speech | 40 | 10% | 16 | 10% | 24 | 10% |
| Multiple/other | 116 | 29% | 52 | 31% | 57 | 24% |
| Ethnicity | ||||||
| Lao Tai | 191 | 47% | 76 | 45% | 115 | 49% |
| Hmong/Lu Mien | 184 | 45% | 79 | 47% | 105 | 44% |
| Other | 30 | 7% | 13 | 8% | 17 | 7% |
| In school (age 6+) | ||||||
| Yes | 182 | 55% | 74 | 54% | 108 | 55% |
| No | 151 | 45% | 64 | 46% | 87 | 45% |
[i] *Significant difference (p < 0.05).
NB: Percentages may not equal 100% due to rounding.
Caregiver perceived knowledge
Table 2 presents caregiver perceived knowledge across each service type. Perceived knowledge was highest for assistance with daily tasks beyond what would be typical for a child without disability of the same age (88%, n = 357). Only half of caregivers reported knowledge about the specific needs of their child for disability-related healthcare services (49%, n = 197), assistive technology (45%, n = 181), and disability-related support at school (56%, n = 90).
Unmet need for disability-related services
Table 3 outlines the unmet need for disability-related services. Across all domains expressed need was high, especially for disability-related healthcare (93%). However, there were large gaps in access, particularly for assistive technology (71%). Among children accessing services, caregivers generally reported being satisfied with the quality, although nearly a third of caregivers were dissatisfied with disability-related health services received (29%). Unmet need across all domains was high, particularly for assistive technology (77%).
Table 3
Unmet needs for disability-related supports (n = 405).
| EXPRESSED NEEDS | DID NOT ACCESS1 | UNSATISFIED2 | UNMET NEED1 | |
|---|---|---|---|---|
| Healthcare | 378 (93%) | 146 (39%) | 67 (29%) | 213 (56%) |
| Assistive technology | 305 (75%) | 216 (71%) | 18 (20%) | 234 (77%) |
| Daily assistance | 260 (64%) | 121 (45%) | 29 (21%) | 150 (58%) |
| School support3 | 88 (54%) | 29 (33%) | 7 (12%) | 36 (41%) |
[i] 1Among those needing service, 2Among those who accessed, 3Among children in school (n = 182).
Predictors of expressed need for disability-related services
In Appendix B, predictors of expressed need are presented. Few variables were found to be predictors of expressed need for disability-related healthcare and assistive technology. Expressed need for assistance with daily tasks significantly decreased with child age. Caregivers of children aged 6–12 years were 20% less likely to report need than caregivers of children aged 0–6 years (aRR = 0.8, 95% CI 0.7–1.0), whilst caregivers of children aged 12–18 years were 30% less likely (aRR = 0.7, 95% CI 0.6–0.8). Expressed need for daily assistance also significantly varied by impairment type, with caregivers of children with cognitive/learning impairment (aRR = 1.3, 95% CI 1.1–1.6) and multiple/other impairment (aRR = 1.2, 95% CI 1.0–1.4) more likely to report need compared to caregivers of a child with a physical impairment. Caregivers of children with sensory (aRR = 0.7, 95% CI 0.5–1.0) and speech impairment (aRR = 0.7, 95% CI 0.5–0.9) were 30% less likely to express need, compared to caregivers of a child with a physical impairment.
Predictors of unmet need for disability-related services
In Table 4, predictors of unmet need for disability-related support are presented. Compared to participants from the Lao Tai ethnic group, caregivers from other ethnic minorities were significantly more likely to report unmet need for healthcare services related to their child’s disability (aRR = 1.3, 95% CI 1.1–1.7). Additionally, wealth was a statistically significant predictor of unmet need for several services. Caregivers from the bottom two (40%) wealth quintiles were 40% more likely to report unmet need for healthcare (aRR = 1.4, 95% CI 1.2–1.7), 20% more likely to report unmet need for assistive technology (aRR = 1.2, 95% CI 1.1–1.4), and 40% more likely to report unmet need for daily support (aRR = 1.4, 95% CI 1.1–1.7), compared to wealthier families (top 60%). Conversely, caregiver perceived knowledge significantly reduced reporting for unmet need of disability-related services. Caregivers with good perceived knowledge were 30% less likely to report unmet need for healthcare related to their child’s disability (aRR = 0.7, 95% CI 0.6–0.9), assistive technology (aRR = 0.7, 95% CI 0.6–0.8), and daily support (aRR = 0.7, 95% CI 0.5–0.9), compared to caregivers with limited perceived knowledge. No other variables were found to be predictors of unmet need, including disability type.
Table 4
Predictors of unmet need for disability-related supports.
| HEALTHCARE | ASSISTIVE TECHNOLOGY | DAILY ASSISTANCE | ||||
|---|---|---|---|---|---|---|
| % | aRR (95% CI) | % | aRR (95% CI) | % | aRR (95% CI) | |
| Child sex | ||||||
| Male | 59 | Ref | 77 | Ref | 57 | Ref |
| Female | 53 | 0.9 (0.8–1.1) | 76 | 1.0 (0.9–1.1) | 58 | 1.0 (0.8–1.2) |
| Child age | ||||||
| 0–6 | 54 | Ref | 81 | Ref | 59 | Ref |
| 6–12 | 54 | 1.0 (0.8–1.2) | 75 | 0.9 (0.8–1.1) | 60 | 1.1 (0.8–1.4) |
| 12–18 | 59 | 1.1 (0.8–1.3) | 76 | 0.9 (0.8–1.1) | 54 | 1.0 (0.8–1.3) |
| Child disability type | ||||||
| Physical | 54 | Ref | 75 | Ref | 58 | Ref |
| Sensory | 60 | 1.2 (0.9–1.5) | 76 | 1.0 (0.8–1.2) | 45 | 0.8 (0.5–1.3) |
| Cognitive/learning | 69 | 1.2 (1.0–1.6) | 88 | 1.1 (0.9–1.3) | 55 | 0.9 (0.7–1.3) |
| Speech | 54 | 1.1 (0.8–1.5) | 67 | 0.9 (0.7–1.2) | 39 | 0.8 (0.4–1.4) |
| Multiple/other | 52 | 1.0 (0.8–1.2) | 79 | 1.0 (0.9–1.2) | 66 | 1.1 (0.9–1.4) |
| Ethnicity | ||||||
| Lao Tai | 56 | Ref | 79 | Ref | 59 | Ref |
| Hmong/Lu Mien | 53 | 0.9 (0.8–1.1) | 73 | 0.9 (0.8–1.0) | 56 | 0.8 (0.7–1.1) |
| Others | 83 | 1.3 (1.1–1.7)* | 92 | 1.1 (0.9–1.4) | 65 | 1.0 (0.7–1.6) |
| Relative wealth | ||||||
| Top 60% | 47 | Ref | 69 | Ref | 50 | Ref |
| Bottom 40% | 70 | 1.4 (1.2–1.7)* | 87 | 1.2 (1.1–1.4)* | 68 | 1.4 (1.1–1.7)* |
| Caregiver1 sex | ||||||
| Male | 61 | Ref | 80 | Ref | 64 | Ref |
| Female | 52 | 0.9 (0.7–1.0) | 73 | 0.9 (0.8–1.0) | 50 | 0.8 (0.6–1.0)* |
| Caregiver perceived knowledge | ||||||
| Limited | 69 | Ref | 92 | Ref | 66 | Ref |
| Good | 43 | 0.7 (0.6–0.9)* | 61 | 0.7 (0.6–0.8)* | 48 | 0.7 (0.5–0.9)* |
| District | ||||||
| Pek | 51 | Ref | 74 | Ref | 56 | Ref |
| Khoun | 44 | 0.8 (0.6–1.1) | 76 | 0.9 (0.8–1.1) | 52 | 0.8 (0.6–1.2) |
| Phoukoud | 53 | 1.0 (0.7–1.3) | 68 | 0.8 (0.6–1.0)* | 55 | 0.9 (0.6–1.2) |
| Nonghed | 71 | 1.2 (0.9–1.6) | 88 | 0.9 (0.8–1.1) | 73 | 1.0 (0.7–1.5) |
| Kham | 80 | 1.3 (1.0–1.8) | 90 | 1.0 (0.8–1.2) | 67 | 0.9 (0.6–1.4) |
[i] *Significant association (p < 0.05); 1Respondent, who is typically the primary caregiver.
Discussion
In this study, we observed a large disparity between disability-related service need and service access among children with disabilities in Lao PDR. Although quality of service provision – for those who did access them – was generally reported as satisfactory by caregivers, unmet need was high across all four services (healthcare related to the child’s disability, assistive technology, assistance for daily life activities, and disability-related school support). Notably, unmet need was highest for assistive technology. Unmet need was related to poorer socioeconomic status and perceived knowledge of the caregiver, across all services.
High levels of unmet need for disability-related services is consistent with the existing global literature. Numerous studies have demonstrated barriers to access for people with disabilities to both disability-related and general services, including rehabilitation, healthcare, education, and assistive technology (UNDESA 2024; Bright, Wallace and Kuper 2018). Barriers to access are consistently related to the limited availability of services, financial barriers, stigma and discrimination from communities and service providers, and exclusion of people with disabilities from national policy (Bani Odeh and Lach 2024; Boot et al. 2018; Bright, Wallace and Kuper 2018; Hashemi et al. 2022; Thomas et al. 2023).
This study found a consistent relationship between access to services and caregiver perceived knowledge of needed support and available services for children with disabilities. Although many caregivers recognised and expressed a need for support under each service, fewer reported knowledge on the specific type of support needed. Caregivers with good knowledge on the specific type of support required were less likely to report unmet need for services that would help improve inclusion and outcomes for children with disabilities. These findings align with existing literature highlighting the role of caregiver knowledge in the utilisation of services for children with developmental and physical disabilities (Adugna et al. 2020; Vampere, Dassah and Tawiah 2024). In this discussion, it is important to reflect on the possibility of reverse causality. It is plausible that caregivers who are already accessing services, particularly those that include counselling or information-sharing components, may report higher levels of knowledge as a result of these interactions. In such cases, access to services contributes to the improvement of caregiver knowledge. Regardless, the findings suggest that strengthening caregiver knowledge and capacity can contribute to improved access to disability-related services and improved outcomes for children with disabilities. A recent systematic review of caregiver skills training for caregivers of children with neurodevelopmental disorders found benefits for both children and caregivers, including improvements in child development, improved caregiver skills and knowledge, improved caregiver mental health, and improved family relations (Reichow et al. 2024).
This study further highlights a significant association between household poverty and unmet need among children with disabilities. Again, this is consistent with the global literature, with financial constraints a consistent barrier to service access for families and children with disabilities. Costs associated with service access include the direct cost of the service (e.g. purchase and maintenance of an assistive device), as well as indirect costs, such as the cost of accessible transport and lost caregiver income due to caregiving. These costs can be substantial. For example, in Uganda, the cost for families of children with developmental disabilities was US $949 per year, more than the average national income (Katumba et al. 2023).
These findings can be interpreted according to the ICF with regards to the impact of unmet need for services on child participation (WHO 2001). Findings show that unmet need for disability-related services is a significant environmental barrier in the lives of children with disabilities in Lao PDR. Personal factors (e.g. family socioeconomic status) and impairment type predict unmet need, whilst caregiver knowledge may act as a facilitator to service access. This is consistent with the ICF model’s view that functioning and disability are shaped by the dynamic interaction of its components. Within the ICF framework, limited access to appropriate disability-related services may result in worsening impairments, secondary complications and delayed development. These impairments can reduce functional capacity, thereby increasing activity limitations and restricting participation in everyday life, including education, play and social interaction.
Social protection, including cash, in-kind benefits, and universal health coverage, is an important and increasingly used strategy for combatting poverty and improving participation amongst people with disabilities and their families (ILO 2017; UNICEF and ILO 2023). However, there is limited evidence on the impact of social protection for families with a child with disabilities (Banks et al. 2016; Kidd et al. 2019). In Lao PDR, the National Health Insurance scheme is available, but out-of-pocket costs can be prohibitive, especially for rural and low-income households (World Bank 2017). The scheme also has limited coverage of disability-related health services and the services covered are most relevant for people with physical disabilities (ILO 2025). Improving population coverage and coverage of disability-related health services in the National Health Insurance scheme, combined with addressing indirect costs of seeking care (e.g. time out of work, transport), could help improve access of children with disabilities to needed services.
This study has focused on individual-level predictors of unmet need, but it is important to also consider significant structural barriers in Lao PDR, that contribute to unmet need, including limited service infrastructure and insufficient funding for disability services, as noted in the report from the Committee on the Rights of Persons with Disabilities (UN Committee on the Rights of Persons with Disabilities 2022). Addressing unmet need requires both systems-level investments to expand service availability and targeted supports to reduce the economic and knowledge barriers for families found in this study. As the Committee recommends in their report, a multi-level approach is essential for ensuring children with disabilities can access needed services. Among their recommendations is the directive to expand rehabilitation systems to ensure that children with disabilities have access on the basis of their individual requirements, improve information sharing on the importance of and availability of disability-services, enhance accessibility of health-facilities, provide links to affordable and accessible transport, and mainstream people with disabilities into the national social protection strategy, to name a few.
Strengths and limitations
Regarding strengths, this study was conducted under a pre-registered protocol, providing methodological transparency to help reduce the risk of bias in study design, data collection, and analysis (Banks et al. 2024). Additionally, it is among the few studies in Lao PDR that comprehensively explores caregiver-reported perceived knowledge, perceived service needs, and reported access of children with disabilities across multiple services, including healthcare, assistive technology, daily support, and support at school. The study provides robust evidence of disparities in access, reinforcing the need for a targeted policy response. The inclusion of socioeconomic and demographic predictors strengthens the validity of the findings and supports their use in policy and programme design. Finally, the study’s large, diverse and population-based sample increases the generalisability of findings, which could contribute to considerations for children with disabilities in other rural settings in Lao PDR.
Nevertheless, this study has several limitations that should be considered when interpreting the findings. First, caregivers self-reported their child’s needs and their perceived knowledge on the specific support required. It is possible that caregivers had significant knowledge gaps on their child’s support needs, even amongst those that self-reported good knowledge on required support. Given the relatively limited caregiver perceived knowledge found overall, self-reporting of need may represent an underestimation or overestimation. Second, reported satisfaction with services may be influenced by caregiver knowledge of available services, expectations regarding service quality, and prior experiences across the four services. Caution should be exercised when interpreting satisfaction data, as caregivers with limited knowledge of what services should be available or what constitutes comprehensive disability support may report satisfaction even when significant service gaps exist. As a result of these two limitations, the self-reported prevalence of unmet need may reflect not only service gaps, but also knowledge gaps and variations in expectations. Third, this study focused on four key service domains, and while these represent critical areas of need, children with disabilities and their families may experience unmet need across a broader range of additional support needs that were not captured in our study. For instance, we did not assess unmet need related to transportation services, which are essential for accessing education, healthcare, and community participation. Fourth, 45% of school-aged children were not enrolled in school and this could be considered an unmet need, not including in our analysis. However, we did not measure the reasons why children are not in school and it is therefore plausible that children may be out of school for reasons unrelated to the need for and provision of disability-related school supports (e.g. inability to afford school fees). Finally, the identification of children with disabilities in Kham was dependent on report from village authorities only, without verification by the Washington Group Child Functioning Module. Despite receiving training on disability identification, the village authorities may have over- or under-estimated disability.
Conclusion
This study demonstrates the high unmet need for disability-related services for children with disabilities, notably for assistive technology. Unmet need is shaped by several predictors. As demonstrated in this study, these predictors include caregiver and family characteristics, such as caregiver knowledge and household wealth. Given the association of unmet need and family characteristics found in this study, family support (such as social protection) may play a critical role within a multi-sectoral response to address unmet need for disability-related services for children with disabilities in Lao PDR.
Additional Files
The additional files for this article can be found as follows:
Appendix A
Survey questions on access to disability-related services and caregiver perceived knowledge. DOI: https://doi.org/10.16993/sjdr.1318.s1
Data Accessibility Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Acknowledgements
We would like to thank all participants for providing their time to take part in this study. Moreover, thank you also to the team at UNICEF Lao PDR, and in particular to, Maryam Abdu and Amphayvan Chanmany for their support in informing the study design and identifying participants. Electronic data solutions were provided by LSHTM Global Health Analytics (odk.lshtm.ac.uk).
Author Contributions
Bounhome Soukkhaphone: Writing – original draft, visualization, validation, resources, project administration, methodology, investigation, conceptualization. Nathaniel Scherer: Writing – review and editing, visualization, validation, resources, project administration, methodology, investigation, conceptualization. Ketmany Chanthakoummane: Writing – review and editing, visualization, validation, resources, project administration, methodology, investigation, conceptualization. Anousin Homsana: Writing – review and editing, visualization, formal analysis, data curation. Mark T. Carew: Writing – review and editing, visualization, validation, methodology, investigation, conceptualization. Hannah Kuper: Writing – review and editing, visualization, validation, supervision, project administration, methodology, investigation, funding acquisition, conceptualization. Lena Morgon Banks: Writing – review and editing, visualization, validation, supervision, resources, project administration, methodology, investigation, formal analysis, data curation, conceptualization. Latsamy Siengsounthone: Writing – review and editing, visualization, validation, resources, project administration, methodology, investigation, data curation, conceptualization.
Bounhome Soukkhaphone, Nathaniel Scherer, Lena Morgon Banks and Latsamy Siengsounthone equal contribution.