Article
This article was published on Campbell Systematic Reviews by Xanthe Hunt, Ashrita Saran, Howard White, Hannah Kuper on 06 February, 2025
https://doi.org/10.1002/cl2.70016
Abstract
Background
People with disabilities are consistently falling behind in educational outcomes compared to their peers without disabilities, whether measured in terms of school enrolment, school completion, mean years of schooling, or literacy levels. These inequalities in education contribute to people with disabilities being less likely to achieve employment, or earn as much if they are employed, as people without disabilities. Evidence suggests that the gap in educational attainment for people with and without disabilities is greatest in low- and middle-income countries (LMICs). Exclusion of people with disabilities from mainstream education, and low rates of participation in education of any kind, are important issues for global equity. Interventions which might have a positive impact include those that improve educational outcomes for people with disabilities, whether delivered in specialist or inclusive education settings. Such interventions involve a wide range of initiatives, from those focused on the individual level – such as teaching assistance to make mainstream classes more accessible to children with specific learning needs – to those which address policy or advocacy.
Objectives
The objectives of this review were to answer the following research questions: (1) What is the nature of the interventions used to support education for people with disabilities in LMICs? (2) What is the size and quality of the evidence base of the effectiveness of interventions to improve educational outcomes for people with disabilities in LMICs? (3) What works to improve educational outcomes for people with disabilities in LMICs? (4) Which interventions appear to be most effective for different types of disability? (5) What are the barriers and facilitators to the improvement of educational outcomes for people with disabilities? (6) Is there evidence of cumulative effects of interventions?
Search Methods
The search for studies followed two steps. Firstly, we conducted an electronic search of databases and sector-specific websites. Then, after initial screening, we examined the reference lists of all identified reviews and screened the cited studies for inclusion. We also conducted a forward search and an ancestral search. No restrictions in terms of date or format were placed on the search, but only English-language publications were eligible for inclusion.
Selection Criteria
In our review, we included studies on the basis that they were able to detect intervention impact. Descriptive studies of various designs and methodologies were not included. We also excluded any study with a sample size of fewer than five participants. We included studies which examined the impact of interventions for people with disabilities living in LMICs. There were no restrictions on comparators/comparison groups in included studies. However, to be eligible for inclusion, a study needed to have both an eligible intervention and an eligible outcome. Any duration of follow-up was eligible for inclusion.
Data Collection and Analysis
We used EppiReviewer for bibliographic management, screening, coding, and data synthesis. Eligibility was assessed using a predesigned form based on the inclusion criteria developed by the authors. We piloted all coding sheets with at least five studies before use. The form allowed for coding of multiple intervention domains and multiple outcomes domains. The entire screening process was reported using a PRISMA flow chart. We screened all unique references from our search title and abstract, with two independent reviewers determining relevance, and repeated this process for full texts. Data was extracted from studies according to a coding sheet. Coding included: (1) extraction of basic study characteristics, (2) a narrative summary of procedures and findings (including recording of iatrogenic effects), (3) a summary of findings/results table, (4) an assessment of confidence in study findings, and (5) creation of a forest plot of effect sizes. A third data collector, a research associate, checked the results of this process. Confidence in study findings was assessed using a standardised tool. All coding categories were not mutually exclusive and so multiple coding was done where an intervention covered more than one category of intervention.
Main Results
Twenty-eight studies were included in this review. Most studies (n = 25) targeted children with disabilities. Only two studies directly targeted family members, and the remaining three focused on service providers. Individuals with intellectual or learning and developmental impairments were most frequently targeted by interventions (n = 17). The category of interventions most represented across studies was ‘Educational attainment support’, for instance, a reading comprehension intervention that combined strategy instruction (graphic organisers, visual displays, mnemonic illustrations, computer exercises, predicting, inference, text structure awareness, main idea identification, summarisation, and questioning) for children with dyslexia. The second most common category of intervention was ‘Accessible learning environments’, for instance, programmes which aimed to improve social skills or to reduce rates of victimisation of children with disabilities in schools. Regarding intervention effects, included studies concerned with ‘Conditions for inclusion of people with disabilities in education’ showed a moderately significant effect, and one study concerned with teacher knowledge showed a significant effect size. Among the 18 studies included in the analysis of intervention effects on ‘Skills for learning’, 12 interventions had a significant effect. When considering the effect of interventions on different outcomes, we see that the effect on literacy, cognitive skills, handwriting, and numeracy are significant. All these effects are large but are based on a low number of studies. The studies concerned with speech and school behaviour show no significant effect of intervention. Across studies, heterogeneity is high, and risk of publication bias varies but was frequently high. All but one study received an overall rating of low confidence in study findings. However, this lack of confidence across studies was largely due to the use of low-rigour study designs and was not always reflective of multiple points of weakness within a given study.
Authors' Conclusions
Children with disabilities fall behind in educational outcomes as the current school systems are not set up to teach children with different impairment types. There is no one ‘magic bullet’ intervention which can equalise health outcomes for this group. A twin-track approach is needed, which both addresses the specific needs of children with disabilities but also ensures that they are included in mainstream activities (e.g., through improving the skills of teachers and accessibility of the classroom). However, currently most interventions included in this systematic review targeted individual children with disabilities in an attempt to improve their functioning, skills, and competencies, but did not focus on mainstreaming these children into the school by system-level or school-level changes. Consequently, a focus on evaluation of interventions which target not just the individual with a disability but also their broader environment, are needed.
1 PLAIN LANGUAGE SUMMARY
1.1 Title
A range of individual-level interventions work to improve educational outcomes among people with disabilities in low- and middle-income countries, but there is little research on systemic or school-level change.
1.2 The review in brief
A range of interventions work to improve educational outcomes among people with disabilities, but these are mostly targeted at people with disabilities. More systemic approaches are needed to improve rates of access to, and likelihood of successful engagement in, education.
1.3 What is this review about?
People with disabilities often fall behind in education compared to their peers without disabilities. This is true for enrolment, retention, and completion of education. These inequalities in education contribute to people with disabilities being less likely to gain employment and earn as much as people without disabilities. The gap in educational attainment between people with and without disabilities is largest in LMICs. There is an urgent need to address barriers to the inclusion of people with disabilities, and test approaches to improve their access to and the success in formal and non-formal educational programmes.
1.4 What is the aim of this review?
For this Campbell systematic review, we wanted to analyse and then summarise the findings from research studies that evaluated interventions to improve the educational outcomes of people with disabilities in LMICs.
1.5 What are the main findings of this review?
The review shares findings from a range of interventions and outcomes that were identified across 28 studies. Most of the studies included were aimed at children with disabilities, with a few targeting family members or service providers. People with intellectual or learning and developmental impairments were most frequently targeted by interventions. Eight of the included studies were from India, four were from Iran, two were from China, two were from South Africa and two were from Egypt. One study from each of the following countries was also included: Brazil, Jordan, Kenya, Lebanon, Romania, Turkey, Malaysia, Nigeria, Uganda, and Zambia. Few studies reported whether their setting was urban or rural. Most commonly, interventions were delivered in classrooms in mainstream or inclusive settings, followed by specialist school and resource rooms of inclusive schools.
The category of interventions most commonly represented across studies were those aimed at providing support for educational attainment, followed by those focused on improving the accessibility of learning environments. Educational attainment (including skills for formal learning in schools and skills for life) was the most commonly reported outcome. This was followed by more accessible learning environments, such as strengthened learning/social environment(s) and improved social inclusion.
All but one study received an overall rating of low confidence in study findings. However, low ratings were mostly due to the use of low-rigour study designs and was not always reflective of weakness in the actual study. Generally, methodological details were poorly reported.
1.6 What do the findings of this review mean?
Many included interventions were effective at improving children's functioning, skills, and competencies, but did not focus on institutional (i.e., systemic or school-level) changes. In terms of expanding the research evidence available, strong methodological procedures should be followed and reported on to allow for thorough assessment and comparisons across interventions. Where possible, interventions should be evaluated in terms of concrete outcomes like school completion. Larger sample sizes that include and track outcomes for diverse demographic profiles would help to increase the rigour and reliability of findings, as would the use of standardised measures.
It is well established that a twin-track approach is needed to improve inclusion and outcomes for people with disabilities, meaning a focus both on targeting their specific needs but also ensuring they are included in mainstream activities. However, this review showed that most included interventions tried to improve children's functioning, skills, and competencies, but did not focus on efforts for mainstreaming through institutional (i.e., systemic or school-level) changes. There is a need for evaluation of interventions which target not only the individual with a disability, but also ensure inclusion in their broader environment(s). Efforts should also be made to integrate measures of disability within mainstream education impact evaluations and other demographic/household surveys that include education outcomes, and existing non-targeted government programmes should evaluate whether they are effective in improving educational outcomes for people with disabilities.
1.7 How up-to-date is this review?
The review authors searched for studies up to March 2022. This Campbell Systematic Review was published in February 6, 2025.