Factors influencing access to and participation in rehabilitation for people with lower limb amputation in East, South, and Southeast Asian developing countries: the perspective of rehabilitation professionals – a qualitative study

Figures & data

Table 1. Theme: Client/Patient- Access and participation factors at Level-1 of HCDSA, country and key outcomes.

Sub-themes (n) Country ^(Participant no.)	Access to rehabilitation	Participation in rehabilitation
	Domain of factors (n) Key factors ^(Participant no.)	Domain of factors (n) Key factors ^(Participant no.)
Individual Patient- Characteristics (n = 24) Afghanistan ^(1,9) Bangladesh ^(2, 3, 4, 11, 13) Cambodia ^(10, 14, 17) India ^(7) Indonesia ^(16) Malaysia ^(19) Nepal ^(20, 21, 25) Pakistan ^(5, 6) Sri Lanka ^(12, 22, 27) Thailand ^(15, 18) Vietnam ^(23)	Gender (n = 19) Women need accompanied by men from their family ^(1,2,5,6,9,11,13,16,17,21)^a Women are not prioritized ^(2,6,7,11,16,25,27)^a Women patients need/prefer women rehabilitation professional ^(2,3,4,7,10,11,14,22,23)^a	Gender (n = 19) Women need accompanied by men from their family ^(1,2,5,6,9,11,13,16,17,21)^a Women are not prioritized ^(2,6,7,11,16,25,27)^a Women patients need/prefer women rehabilitation professional ^(2,3,4,7,10,11,14,22,23)^a
	Complications (n = 5) Delayed access results in contracture/deformity requiring long pre-prosthetic management ^(1,5,9,20,22)^a	Complications (n = 5) Delayed access results in contracture/deformity requiring long pre-prosthetic management ^(1,5,9,20,22)^a
	Literacy level (n = 4) The lower educated believe they are cursed and hide ^(11) Higher literacy level^(2,4,11,19)^a	Literacy level (n = 2) Higher literacy level^(4,19)^a
	Religion (n = 6) Muslim women don’t want to be seen by professional men ^(4,12,13,15,18,22)^a	Religion (n = 6) Muslim women don’t want to be seen by professional men ^(4,12,13,15,18,22)^a
Individual Patient- Skills & Resources (n = 24) Afghanistan ^(1,9) Bangladesh ^(2,3,4,11,13) Bhutan ^(26) Cambodia ^(10,14,17) India ^(7) Indonesia ^(16,24) Malaysia ^(19) Nepal ^(21,25) Pakistan ^(5,6) Sri Lanka ^(12,22) Thailand ^(8,15,18)	Economic (n = 14) Cannot afford rehabilitation and related cost- accepts disability ^(4,6,7,9,11,17,24)^a Patient daily labourer losing, income during rehab ^(8,13,14,16)^a	Economic (n = 16) Cannot afford rehabilitation and related costs- accepts disability ^(4,6,7,9,11,12,13,16,17,19,21,24,25)^a Patient daily labourer losing income during rehab ^(4,13,14,26)^a
	Attitude (n = 12) Difficulty accepting disability, lost confidence and hiding from society ^(2,3,11,14,17)^a Uncertainty about rehabilitation outcomes ^(2,3,7,19,21,24,25)	Attitude (n = 16) Difficulty accepting disability, lost confidence and hiding from society ^(1,2,3,14)^a Due to life demands work is a priority over rehabilitation ^(3,4,13,19,24,25,26)^a Follow-up only when they experience serious problem ^(4,5,12,13,14,15,16,18,22,25,26)
	Information (n = 15) Lack of awareness/information about rehabilitation services ^(2,3,6,7,9,12,14,21,22,24,25)^a Access to social media helps provide information about rehabilitation services^(2,4,5,6,10,19,21)	Information (n = 0) No factors identified
	Prosthetic Improvisation (n = 0) Not applicable	Prosthetic Improvisation (n = 16) Patients try to improvise prosthesis repairs to skip follow-up ^(3,5,6,7,9,10,12,13,14,15,17,18,21,22,24,25) Self-improvisation results in complete damage to the prosthesis ^(5,7,10,15,21,22,25)

^aFactors impacting both access to and participation in rehabilitation.

Italic text- Factors found to be an enabler – non-italic text are barriers for access to and participation in rehabilitation.

Table 2. Theme: Care Team – Access and participation factors at Level-2 of HCDSA, country and key outcomes.

Sub-themes (participant number) Country ^(Participant no.)	Access to rehabilitation	Participation in rehabilitation
	Domain of factors (participant number) Key factors ^(Participant no.)	Domain of factors (participant number) Key factors ^(Participant no.)
Team characteristics and functions (n = 28) Afghanistan ^(1,9) Bangladesh ^(2,3,4,11,13) Bhutan ^(26) Cambodia ^(10,14,17) India ^(7) Indonesia ^(16,24) Malaysia ^(19) Myanmar ^(28) Nepal ^(20,21,25) Pakistan ^(5,6) Sri Lanka ^(12,22,27) Thailand ^(8,15,18) Vietnam ^(23)	Peers (n = 0) No factors reported	Peers (n = 14) No structured peer support groups available ^(1,2,3,5,7,8,11,18,20,21,22,25,26) Rehabilitation staff with a disability set examples ^(1,2,3,12)
	Families (n = 9) Women or children dependent on men from their family for rehabilitation ^(1,9,11,12,14,16,17,18)^a Family members do not support women/children to access rehabilitation ^(1,6,9,11,12,14,16,17,18)^a	Families (n = 11) Women or children dependent on men from their family for rehabilitation ^(1,9,11,12,14,16,17,18)^a Family members do not support women/children to access rehabilitation ^(1,6,7,9,11,24)^a
	Professional challenges (n = 27) Lack of professions and professionals in LLA rehabilitation ^(1,7,8,9,10,12,15,18,19,21,22,28)^a Professional education availability and admission ^(3,5,9 10,12,13 14,15,23,24,28) Insufficient professional women available ^(5,7,9,10,13,14,22,25)^a Professional women suffer gender-based discrimination ^(6,7,9,13,22)^a Negative societal attitudes about womens’ work roles ^(4,5,9,10,12,14,16,17)^a Rehabilitation work thought to be too heavy/dangerous for women ^(3,4,9,10,16,22,27)^a Professional women leave the profession after marriage/having children ^(5,22,27)^a Professional women do not want/not allow to work in a different city from their home ^(4,5,11,14)^a People working in the profession without proper training ^(3,13,19,27,28)^a Non-certified professionals’ malpractice ^(13,19,21,22)^a Professionals leaving the profession due lacking in career progression ^(10,14,21,24,28)^a Professionals are not working in a team ^(7,8,14,27)^a No gender discrimination within profession^(2,3,4,5,10,11,12,17,22,23,24,25,26,28)^a Unclear understanding of role of different rehabilitation professionals ^(1,2,8,9,11,25) Professionals from one profession working in another professional role ^(1,10,13)	Professional challenges (n = 28) Lack of professions and professionals in LLA rehabilitation ^(1,7,8,9,10,12,15,18,19,21,22,28)^a Insufficient professional women available ^(5,7,9,10,13,14,22,25)^a Professional women suffer gender-based discrimination ^(6,7,9,13,22)^a Negative societal attitudes about womens’ work roles ^(4,5,9,10,12,14,16,17)^a Rehabilitation work thought to be too heavy and dangerous for women ^(3,4,9,10,16,22,27)^a Professional women leave the profession after marriage/having children ^(5,22,27)^a Professional women do not want/not allow to work in a different city from their home ^(4,5,11,14)^a People working in the profession without proper training ^(3,13,19,27,28)^a Non-certified professionals’ malpractice ^(13,19,21,22)^a Professionals leaving the profession due lacking in career progression ^(10,14,21,24,28)^a Professionals are not working in a team ^(7,8,14,27)^a P&O is heavy, dirty, dangerous work ^(3,8,14,15) Less male professionals available in the country ^(8,12,15,24) No gender discrimination within profession^(2,3,4,5,10,11,12,17,22,23,24,25,26,28)^a
		Only physiotherapist and PO works as a team ^(1,2,3,4,5,6,8,10,11,12,13,14,15,16,18,20,22,24,25,26,28) Other professional available (external to team of the setting) Physiotherapist ^(19) Occupational Therapist ^(12,13,16,20) Speech and Language Therapist ^(12) Social worker ^(12,25) Physician ^(1,11,12,18,20,22,26) Surgeons ^(1,6,13,26) Nurse ^(12,18) Rehabilitation specialist ^(12,16,28) Wheelchair technician ^(20) Psychologist/psychiatrist ^(6,25) Nutritionist ^(12) Vocational counsellor ^(26) Field officer ^(6,28) Only P&O working in some/private centres ^(2,5,19,21,27) Professional conflict amongst professionals ^(1,2,3,4,5,7,8,11,12,14,19,21,22,24,25,26) Rehabilitation specialist the sole decision maker ^(15,16,17,19) Team members co-operate^(1,2,6,10,13,14,17,20,23,26,27,28)
External influences (n = 25) Afghanistan ^(1,9) Bangladesh ^(2,3,4,11,13) Bhutan ^(26) Cambodia (10,14,17) India ^(7) Indonesia ^(24) Malaysia ^(19) Myanmar ^(28) Nepal ^(21,25) Pakistan ^(5,6) Sri Lanka ^(12,22,27) Thailand ^(15,18) Vietnam ^(23)	Referral (n = 25) No involvement of rehabilitation professionals/services in acute care ^(1,3,5,9,10,13,14,22,28) Patient sent home without referral for rehabilitation ^(1,2,3,4,5,6,10,11,13,14,19,22,25,28) Surgeons/acute care professional not aware of rehabilitation services ^(3,4,5,10,11,14,19,25,28) No/weak referral system for rehabilitation ^(4,7,11,27) Self-referral after getting information from different sources^(2,5,10,17,22,25,27,28) Other regional hospitals refer patients^(12,17,18,26) Patients refer another patient to rehabilitation^(2,3,4,5,7,10,14,17,22,25,27,28) Physicians refer patients^(7,12,15,18,19,21,23,24,26,27) Other NGOs referring patients for rehabilitation^(2,3,7,11)	Referral (n = 0) No factors reported
	Surgical considerations (n = 6) Surgeons/acute care professionals not aware of/considering ideal stumps for prosthesis ^(1,9,11,19,26,28)^a	Surgical considerations (n = 6) Surgeons/acute care professionals not aware of/considering ideal stumps for prosthesis ^(1,9,11,19,26,28)^a

^aFactors impacting both access to and participation in rehabilitation.

Italic text- Factors found to be an enabler – non-italic text are barriers for access to and participation in rehabilitation.

Table 3. Theme: Organization – Access and participation factors at Level-3, level of HCDSA, country and key outcomes.

Sub-themes (participant number) Country ^(Participant no.)	Access to rehabilitation	Participation in rehabilitation
	Domain of Factors (participant number) Key factors ^(Participant no.)	Domain of Factors (participant number) Key factors ^(Participant no.)
Service challenges (n = 28) Afghanistan ^(1,9) Bangladesh ^(2,3,4,11,13) Bhutan ^(26) Cambodia ^(10,14,17) India ^(7) Indonesia ^(16,24) Malaysia ^(19) Myanmar ^(28) Nepal ^(20,21,25) Pakistan ^(5,6) Sri Lanka ^(12,22,27) Thailand ^(8,15,18) Vietnam ^(23)	Availability and location (n = 26) Lack of rehabilitation centre availability ^(1,2,7,8,9,10,11,12,14,15,16,17,18,19,20,21,23,24,25,26,28)^a Need to travel long distances (1-3 day/400-800km) to reach rehabilitation centres ^(1,4,7,11,17,18,19,22,23,25,27,28)^a Rehabilitation centres mostly located in big cities ^(1,7,8,12,14,15,16,20,23,24,26)^a Difficulties accessing rehabilitation from remote places ^(4,6,10,11,12,14,15,17,19,21,23,24,25,26)^a Prosthetic fitting requires prior appointment and wait time ^(1,4,5,15,18,20,23,24,25,28)	Availability and location (n = 26) Lack of rehabilitation centre availability ^(1,2,7,8,9,10,11,12,14,15,16,17,18,19,20,21,23,24,25,26,28)^a Need to travel long distances (1-3 days/400-800km) to reach rehabilitation centres ^(1,4,7,11,17,18,19,22,23,25,27,28)^a Rehabilitation centres mostly located in big cities ^(1,7,8,12,14,15,16,20,23,24,26)^a Difficulties accessing rehabilitation from remote places ^(4,6,10,11,12,14,15,17,19,21,23,24,25,26)^a Prosthesis replacement requires prior appointment and wait time ^(1,4,5,8,15,16,18,20,23,24,25,28) Prosthesis repair requires prior appointment and wait time ^(1,5,8,16,18,20,23,24,25,27,28) On arrival appointments available for repairs^(1,6,14,26)
	Support (n = 20) Rehabilitation funding for LLA: Prosthesis provision- free ^(1,3,5,7,8,16,18,22,26,27,28); not free ^(23) Gait training/other rehabilitation services- free ^(1,5,8,16,18,22,23,26,28);subsidised based on criteria ^(3,15); not free ^(27) Rehabilitation related LLA expenses: No support available for rehabilitation related (transport/food/accommodation) cost ^(5,8,15,16,18,21,22,24,27)^a Not enough support for rehabilitation related costs ^(10,14,17,25,26)^a Service provided as outpatient/no accommodation available ^(16,21,24,27)^a Rehabilitation and related support are short term and depend on NGO fund ^(10,20,25)^a	Support (n = 25) Rehabilitation funding for LLA: Pay service charge for repairs/parts ^(2,3,4,11) Funding for LLA rehabilitation Prosthesis provision- free ^(1,3,5,7,8,16,18,22,26,27,28); not free ^(23)^a Gait training/other rehabilitation services- free ^(1,5,8,16,18,22,23,26,28) ; subsidised based on criteria ^(3,15); not free ^(27)^a Rehabilitation related LLA expenses: No support available for rehabilitation related (transport/food/accommodation) cost ^(2,3,4,5,8,11,13,14,15,16,18,21,22,24,27)^a Not enough support for rehabilitation related costs ^(9,10,17,25,26)^a Service provided as outpatient/no accommodation available ^(13,16,21,24,27)^a Rehabilitation and related support dependent on NGO fund availability ^(10,20,25)^a
	Service model (n = 28) NGOs provide support based on their own funding priorities in each country ^(3,6,11)^a NGO provided services - national/international ^(1,2,3,4,5,7,9,10,11,13,17,20,22,24,25,28) Private organizations provide services ^(1,4,7,11,13,15,17,19,21,23,24,27) Dependency on NGOs for service as no government provision of rehabilitation ^(2,3,4,11,20) Service started in response to natural disaster/conflict/war by NGOs ^(5,12,14,17,22,28) Service mostly provided in tertiary level hospital ^(8,15,16,19,26) Rehabilitation within social welfare instead of health services systems ^(14,28) Rehabilitation for LLA is relatively new service in the country ^(2,3,4,5,6,10,11,13,17,26,28) Community based rehabilitation/mobile camp ^(2,10,16,20,25,28)^a Government provided rehabilitation ^(7,8,12,14,15,16,17,18,19,22,23,24,26,28)^a	Service model (n = 23) NGOs provide support based on their own funding priorities in each country ^(3,6,11)^a Charitable model of service not sustainable ^(8,9,10,12,13,14,20,22,25,28) Community based rehabilitation/mobile camps^(2,10,16,20,25,28)^a Government provided rehabilitation^(7,8,10,12,14,15,16,17,18,19,22,23,24,26,28)^a Volunteer repair centres in distant places^(28)
Service delivery (n = 28) Afghanistan ^(1,9) Bangladesh ^(2,3,4,11,13) Bhutan ^(26) Cambodia ^(10,14,17) India ^(7) Indonesia ^(16,24) Malaysia ^(19) Myanmar ^(28) Nepal ^(20,21,25) Pakistan ^(5,6) Sri Lanka ^(12,22,27) Thailand ^(8,15,18) Vietnam ^(23)	Service quality (n = 15) Government/NGOs provided basic technology doesn’t suit people/professional expectation ^(4,5,7,15,19,22)^a Corruption impacting rehabilitation services ^(1,5,7,13,19,21,25)^a Poor acute care rehabilitation creates negative attitude towards rehabilitation services ^(3,10) Good collaboration among different organization in the refugee camp^(11) Better service quality creates positive awareness^(2,19)	Service quality (n = 21) Government/NGOs provided basic technology doesn’t suit people/professional expectation ^(4,5,7,15,19,22)^a Corruption impacting rehabilitation services ^(1,5,7,13,19,21,25)^a Prosthetic technology does not match the work/environment/cultural norms ^(1,3,4,7,8,15,19,22,23,24,26,28) Poor prosthetic alignment causes component damage ^(4,5,7,8,14,19,25) Transfer of service delivery model from NGO to government reduces service quality ^(10,14,21,22) Poor quality services from government rehabilitation centres ^(7,10,22,23) Private rehabilitation service quality is not good ^(1,2) Refugees camp service quality is better than local community services ^(11) Organizations provide readymade prosthesis without customization ^(13,21) Difficulties accepting prosthesis that does not look like a natural limb ^(18,24) Private rehabilitation service quality is good^(7) Respectful behaviour from professional staff^(7) Government provides expensive technology for army rehabilitation centres^(7) Prosthetic foot matched to the work/environment/cultural norms^(14)
	Service resources (n = 15) Insufficient budget allocation for rehabilitation sector ^(10,15,16,27)^a Prosthetic materials are imported from another country ^(12,18,20,21,22,24,25,26)^a Delay complicates material supply chains ^(5,12,20,21,22)^a No dormitory accommodation available ^(5,18)^a Limited capacity of patient admissions in the centre ^(15) No training opportunities for acute care team ^(10,19,27) Availability of different health professionals in refugees camp setting^(11)	Service resources (n = 15) Insufficient budget allocation for rehabilitation sector ^(10,15,16,27)^a Prosthetic materials are imported from another country ^(12,18,20,21,22,24,25,26)^a Delay complicates material supply chains ^(5,12,20,21,22)^a No dormitory accommodation available ^(5,18)^a Volunteers for repairs in distant places^(28) Availability of small reconstructive surgeries for complicated cases at the rehabilitation centre^(1)
	Service strategy (n = 25) Unavailability of official translation services ^(1,2,3,9,11,13,19,22,25,28)^a Gender imbalance within services ^(6,9,13,18)^a Government’s reliance on private prosthetic rehabilitation ^(19)^a Army rehabilitation centre only accessible by army personnel and their family ^(28) Multi-disciplinary approach for providing services^(3,4,5,7,11,17,20,27)^a Family involved in rehabilitation for women and children^(2,5,6,13,25,28)^a Providing services through mobile camp/Community Based Rehabilitation^(2,3,4,6,9,11,16)^a Recruiting gender balanced staff^(2,3,5,25,28)^a No gender/culture/religious service discrimination^(10,28)^a Collaboration with other organizations^(2,11,16,28)^a Women taking care of women patients^(1,2,3,4,5)^a Providing services to neighbouring country with conflict/war affected people/no service^(6,8,23)^a Awareness programs on different media^(4,5,10,13,14) Rehabilitation centre is a part of acute care hospital^(8,12,13,15,18,24) Professional women rotating between settings to provide services for women^(5,6) Expanding rehabilitation services to different parts of the country^(2) Registering people with LLA in disability support scheme^(8) Home visit to assist patients access to rehabilitation^(19) Women and children prioritised for services^(28)	Service strategy (n = 28) Unavailability of official translation services ^(1,2,3,9,11,13,19,22,25,28)^a Gender imbalance within services ^(6,9,13,18)^a Government’s reliance on private prosthetic rehabilitation ^(19)^a Prosthesis is not locally repairable or another centre ^(7,11,25) Private company only provide prosthesis for government and not any training ^(19) People advised to come only if they experience problems ^(7,16,21,26,28) Multi-disciplinary approach for providing services^(3,4,5,7,11,17,20,27)^a Involve family in rehabilitation for women and children^(2,5,6,13,25,28)^a Providing services through mobile camp/Community Based Rehabilitation^(2,3,4,6,9,11,14,16,17,28)^a Recruiting gender balanced staff^(2,3,5,25,28)^a No gender/culture/religious service discrimination^(10,28)^a Collaboration with other organizations^(2,11,16,28)^a Women taking care of women patients^(1,2,3,4,5)^a Providing services to neighbouring country with conflict/war affected people/no service^(6,8,23)^a Private companies doing systematic follow up^(7,22) NGOs are providing creative concepts to keep people participating in rehabilitation^(7) Providing follow up information/appointment during discharge^(1,2,3,5,9,10,11,12,13,14,15,17,18,20,22,23,24,25,27) Ensuring informed consent for gender issues^(2,3,4,6,13,25) Warranty for prosthetic components^(3) Same day repair services targeted^(3,4) Contact for follow-up/work plan^(6,10,13,15,21,24) Training community-based repair volunteers^(28)

^aFactors impacting both access to and participation in rehabilitation.

Italic text – Factors found to be an enabler – non-italic text are barriers for access to and participation in rehabilitation.

Table 4. Theme: Environment – Access and participation factors at Level-4 of HCDSA, country and key outcomes.

Sub-themes (participant number) Country ^(Participant no.)	Access to rehabilitation	Participation in rehabilitation
	Domain of factors (participant number) Key factors ^(Participant no.)	Domain of factors (participant number) Key factors ^(Participant no.)
Economic factors (n = 28) Afghanistan ^(1,9) Bangladesh ^(2,3,4,11,13) Bhutan ^(26) Cambodia ^(10,14,17) India ^(7) Indonesia ^(16,24) Malaysia ^(19) Myanmar ^(28) Nepal ^(20,21,25) Pakistan ^(5,6) Sri Lanka ^(12,22,27) Thailand ^(8,15,18) Vietnam ^(23)	Cost (n = 24) NGOs are providing subsidised service charges based on criteria ^(2,3,4,7,10,11,13,14,16,25,27)^a Government provides subsidised services ^(8,18,23)^a Rehabilitation related cost is more than cost of rehabilitation itself ^(7,10,14,16,22,24,25,28)^a Private companies’ fees for rehabilitation are expensive ^(1,2,3,5,6,7,9,10,12,13,21,27)^a NGOs provide full free service at the refugee camps^(11) NGOs are providing services free of charge^(1,5,6,9,10,16,28)^a Government hospitals provide free service^(7,12,26)^a	Cost (n = 24) NGOs are providing subsidised service charges based on criteria ^(2,3,4,7,10,11,13,14,16,25,27)^a Government provides subsidised services ^(8,18,23)^a Rehabilitation related cost is more than cost of rehabilitation itself ^(7,10,14,16,22,24,25,28)^a Private companies’ charging fees for rehabilitation services,and it is expensive ^(1,2,3,5,6,7,9,10,12,13,21,27)^a Need to pay for prosthesis replacements ^(18) NGOs are providing services free of charge^(1,5,6,9,10,16,28)^a Government hospitals provide free services^(7,12,26)^a
	Financial support (n = 26) Patients pay for their rehabilitation ^(2,3,4,5,7,8,9,13,16,18,19,20,21,23,24,27)^a NGOs provide financial support for rehabilitation costs^(2,4,5,10,11,13,17,19,20,21,22,23,24,25,27,28)^a Rehabilitation centre social welfare departments provide financial support^(2,3,4,8,11,13,18,24)^a Government health/disability support scheme provides financial support^(6,7,8,10,12,15,17,18,19,20,22,23,24,25,26,28)^a Private insurance systems support rehabilitation cost^(7,16)^a	Financial support (n = 26) Patients pay for their rehabilitation ^(2,3,4,5,7,8,9,13,16,18,19,20,21,23,24,27)^a No/reduced level of support for participation/follow up ^(2,3,4,6,8,20) NGOs provide financial support for rehabilitation costs^(2,4,5,10,11,13,17,19,20,21,22,23,24,25,27,28)^a Rehabilitation centre social welfare departments provide financial support^(2,3,4,8,11,13,18,24)^a Government health/disability support scheme provides financial support^(6,7,8,10,12,15,17,18,19,20,22,23,24,25,26,28)^a Private insurance systems support rehabilitation cost^(7,16)^a
Physical,political,social and cultural factors (n = 28) Afghanistan ^(1,9) Bangladesh ^(2,3,4,11,13) Bhutan ^(26) Cambodia ^(10,14,17) India ^(7) Indonesia ^(16,24) Malaysia ^(19) Myanmar ^(28) Nepal ^(20,21,25) Pakistan ^(5,6) Sri Lanka ^(12,22,27) Thailand ^(8,15,18) Vietnam ^(23)	Societal attitudes (n = 26) Negative attitude and acceptability to disability in community ^(1,2,3,4,5,6,9,11,13,14,16,18,21,22,23,24,25,26,27,28)^a Charitable/sympathetic behaviour ^(7,9,12,14,16,25)^a Improving people’s attitude towards disability through awareness^(2,4,6,10,11,12,13,19,21,25)^a Society accepts people with disability^(8,19,20)^a	Societal attitudes (n = 26) Negative attitude and acceptability to disability in community ^(1,2,3,4,5,6,9,11,13,14,16,18,21,22,23,24,25,26,27,28)^a Charitable/sympathetic behaviour ^(7,9,12,14,16,25)^a Improving people’s attitude towards disability through awareness^(2,4,13,6,10,11,12,19,21,25)^a Society accepts people with disability^(8,19,20)^a Successful outcomes create positive attitudes towards people with disability^(2,4,8)
	Transport and terrain access (n = 20) Roads and transport availability/system in the country difficult to access for people with LLA ^(1,6,9,10,11,12,13,14,16,17,21,23,24,25,26,27,28)^a Mountainous terrain creates mobility difficulties for people with LLA ^(1,6,9,10,13,16,17,23,24,25,26,27,28)^a Environmental factors make it difficult for people to move around their country ^(1,6,16,17,21,28)^a Roads and transport availability/system in the country accessible for people with LLA^(8,15,19)^a	Transport and terrain access (n = 20) Roads and transport availability/system in the country difficult to access for people with LLA ^(1,6,9,10,11,12,13,14,16,17,21,23,24,25,26,27,28)^a Mountainous terrain creates mobility difficulties for people with LLA ^(1,6,9,10,13,16,17,23,24,25,26,27,28)^a Environmental factors make it difficult for people to move around their country ^(1,6,16,17,21,28)^a Roads and transport availability/system in the country accessible for people with LLA^(8,15,19)^a
	Conflict and security issues (n = 13) Long-term conflict/war impacted rehabilitation need and service availability ^(1,5,6,9,10,12,14,17,22,23,25)^a Increasing number of patient due to conflict/war ^(1,5,6,9,28)^a	Conflict and security issues (n = 13) Long-term conflict/war impacted rehabilitation need and service availability ^(1,5,6,9,10,12,14,17,22,23,25)^a Increasing number of patient due to conflict/war ^(1,5,6,9,28)^a
	Policy (n = 21) No/weak government support policy for people with LLA ^(1,2,5,6,9,11,13,14,22,23,25)^a No/lack of rehabilitation service provision for LLA in health policy ^(1,3,5,9,10,11,13,14)^a No/lack of policy implementation in the country ^(2,3,13,14,16,19,25)^a Long bureaucratic system for support services ^(5,7,15,25,27)^a NGO’s interest in specific group/area limits services to other ^(5,11)^a Lack of awareness about rehabilitation in government ^(6,22)^a NGOs forced to leave as their activity is suspicious to the Government ^(22)^a Changing government changes support policies ^(1)^a Military hospitals supported by better health policies related to rehabilitation^(27)^a NGO provided rehabilitation education opportunities^(5)^a Government initiating health supports for rehabilitation^(3,5,12,13)^a Government policy for rehabilitation for LLA is supporting people^(12,26,28)^a Support for child education and supply of study material^(6)^a	Policy (n = 21) No/weak government support policy for people with LLA ^(1,2,5,6,9,11,13,14,22,23,25)^a No/lack of rehabilitation service provision for LLA in health policy ^(1,3,5,9,10,11,13,14)^a No/lack of policy implementation in the country ^(2,3,13,14,16,19,25)^a Long bureaucratic system for support services ^(5,7,15,25,27)^a NGO’s interest in specific group limits services to other ^(5,11)^a Lack of awareness about rehabilitation in government ^(6)^a NGOs forced to leave as their activity is suspicious to the Government ^(22)^a Changing government changes support policies ^(1)^a Military hospitals supported by better health policies related to rehabilitation^(27)^a NGO provided rehabilitation education opportunities^(5)^a Government initiating health supports for rehabilitation^(5,12)^a Government policy for rehabilitation for LLA is supporting people^(12,26,28)^a Support child education and supply of study material^(6)^a
	Service model (n = 3) Rehabilitation separated from mainstream health systems ^(10,14)^a Rehabilitation professional staff recruitment not a priority for government ^(12)	Service model (n = 4) Rehabilitation separated from mainstream health systems ^(10,14)^a Charitable supports accepted for political outcomes ^(8,10,13)
	Context of rehabilitation provider (n = 21) Government regulatory body for the profession Prosthetics & Orthotics Yes ^(6,7,15,20,25,26)^a No ^(1,5,10,11,12,13,14,16,17,22,24,27)^a Physiotherapy Yes ^(6,7,15,16,25,26)^a No ^(1,5,10,11,12,13,14,17,27)^a Control of regulatory body in the country not effective ^(8,15,16,20,21,24,25)^a Professional body available in the country: Prosthetics & Orthotics ^(1,5,6,7,10,11,12,13,14,17,20,24)^a Physiotherapy ^(1,5,6,7,10,11,12,13,14,17,20)^a Government in process of creating a regulatory body^(3,4,13,17)	Context of rehabilitation provider (n = 19) Government regulatory body for the profession Prosthetics & Orthotics Yes ^(6,7,15,20,24,25,26)^a No ^(1,5,10,11,12,13,14,16,17,22,27)^a Physiotherapy Yes ^(6,7,15,16,25,26)^a No ^(1,5,10,11,12,13,14,17,27)^a Control of regulatory body in the country not effective ^(8,15,16,20,21,24,25)^a Professional body available in the country: Prosthetics & Orthotics ^(1,5,6,7,10,11,12,13,14,17,20,24)^a Physiotherapy ^(1,5,6,7,10,11,12,13,14,17,20)^a
	Targeted service provision (n = 8) No information available about the LLA population characteristics in the country ^(1,7,10,17,25,28)	Targeted service provision (n = 0) No factors reported

^aFactors impacting both access to and participation in rehabilitation.

Italic text – Factors found to be an enabler – non-italic text are barriers for access to and participation in rehabilitation.

Table 5. Interview participants demographic information (N = 28).

Country of focus	Nationality	Age (Years)	Sex	DAC Regional Country(s) of experience	Country of education	Level of education	Current role	Work experience (Years)	Current organization type	Work location
Afghanistan	Afghanistan	33	F	Afghanistan, Thailand	Thailand	CAT-1/BScPO	PO	–	NGO	Urban
	Afghanistan	44	M	Afghanistan	Afghanistan, India	BScPT	PT	27	NGO	Rural
Bangladesh	Bangladesh	31	M	Bangladesh	Bangladesh	BScPT	PT	4	iNGO	Rural
	Bangladesh	29	F	Bangladesh	Bangladesh	BScPT	PT	3	NGO	Urban
	Bangladesh	34	M	Bangladesh, Vietnam, Thailand	Vietnam, Thailand	CAT-1/BScPO	PO	12	NGO	Urban
	Bangladesh	33	M	Bangladesh, Vietnam	Vietnam	CAT-2/DipPO	PO	15	Private	Rural
	Bangladesh	31	M	Bangladesh, India, Thailand	India, Thailand	CAT-1/BScPO	PO	14	NGO	Rural
Bhutan	Bhutan	31	M	Bhutan, India	India	CAT-1/BScPO	PO	7	Govt.	Urban
Cambodia	Cambodia	40	M	Cambodia, Sri Lanka, Indonesia, Philippines, Myanmar	Cambodia, Australia	CAT-1/BScPO	PO	23	iNGO	Rural
	Cambodia	41	M	Cambodia	Cambodia, Singapore	BScPT + MScPT	PT	15	iNGO	Urban
	Cambodia	40	F	Cambodia	Cambodia, Australia	CAT-1/BScPO + MS	V.Rehab + PO	15	Govt.	Urban
India	India	48	M	India, Bangladesh,	India	CAT-1/BScPO	PO	–	iNGO	Urban
Indonesia	Indonesia	71	F	Indonesia	Indonesia	PMD + PhD	PMD	47	NGO	Rural
	Indonesia	35	M	Indonesia	Indonesia, Pakistan	CAT-2/DipPO	PO	10	Govt. Uni. Hospital	Urban
Malaysia	Pakistan	35	M	Pakistan, Malaysia	Pakistan	CAT-1/BScPO	PO	14	Private	Urban
Myanmar	Myanmar	45	M	Myanmar	Cambodia, Thailand	CAT-1/BScPO	PO	20	NGO	Rural
Nepal	Nepal	32	M	Nepal, Indonesia, Bangladesh	Nepal	BScPT	PT	12	iNGO	Urban
	Nepal	38	M	Nepal	Cambodia	CAT-2/DipPO	PO	7	Semi-Gov	Rural
	Nepal	42	M	Nepal	Thailand	CAT-1/BScPO	PO	20	Private	Urban
Pakistan	Pakistan	41	M	Pakistan	Pakistan	CAT-1/BScPO	PO	18	iNGO	Rural
	Pakistan	28	M	Pakistan	Pakistan	CAT-1/BScPO	PO	17	NGO	Rural
Sri Lanka	Sri Lanka	50	M	Sri Lanka	Sri Lanka, USA	BScPT + PhD	PT	22	Private	Urban
	Sri Lanka	40	M	Sri Lanka	Sri Lanka, Thailand	CAT-1/BScPO	PO	19	iNGO	Rural
	Sri Lanka	39	F	Sri Lanka, Thailand	Sri Lanka, Thailand	CAT-1/BScPO + MS	PO	10	Govt.	Urban
Thailand	Japan	52	M	Thailand, Bangladesh, Cambodia	Japan	CAT-1/BScPO	PO	31	iNGO	Urban
	Japan	48	M	Thailand	Japan	CAT-1/BScPO	PO	27	Govt. Uni. Hospital	Urban
	Thailand	24	F	Thailand	Thailand	CAT-1/BScPO	PO	5	Govt. Uni. Hospital	Urban
Vietnam	Vietnam	25	F	Vietnam	Vietnam	BScPT	PT	3	Govt.	Urban

DAC: Developing Asian Country; M: Male; F: Female; BScPT: Bachelor level physiotherapy education; MScPT: Masters level physiotherapy education; CAT-1/BScPO: ISPO category 1 or bachelor level prosthetist and orthotist; CAT-2/DipPO: ISPO category 2 or bachelor level prosthetist and orthotist; MS: Master of Science level education; PhD: Doctoral level education; PMD: Physical medicine doctor; PO: Prosthetist and orthotist; PT: Physiotherapist; V.Rehab: Vocational rehabilitation specialist; NGO: Non-government organization; iNGO: International non-government organization; Semi-Gov: Semi-government organization; Uni.Hospital: Hospital attached to a university; Govt.: Government.

Figure 1. Map of participant locations (Created using Google My Maps: https://www.google.com.au/maps/about/mymaps/).

A map of the East, South, and Southeast Asian developing countries with markers showing the spread of participant locations across 13 different countries.

Table 6. Reported socio-demographic characteristics of LLA population in each country.

Country/number of interviews	Most common cause of LLA	Other causes of LLA	Description of most common age of LLA	Common sex of those with LLA	Common socio-economic status those with LLA
Afghanistan (n = 2)	Conflict/war- land mines, gunfire	Trauma, diabetic	Children
Bangladesh (n = 5)	Trauma- RTA and industrial accidents	Pathological- diabetic and other diseases Conflict/war- land mines/gunfire (refugees)	Trauma- active age (18–40 years) Pathological- mid to old age (35–70 years)	Male	Lower socio-economic groups
Bhutan (n = 1)	Trauma- RTA	Pathological- Diabetic and other diseases	40–45 years	Male	Rural & remote area population/farmers
Cambodia (n = 3)	Trauma- RTA and industrial accident	Pathological- Diabetic and other diseases War- gunfire (refugees)	Trauma- active age (>18 years) Pathological- old age	Male	Principal earners
India	Diabetic	Trauma- RTA and industrial accidents	Trauma- active age (>18 years) Pathological- old age (50-60 years)	Male
Indonesia	Trauma- RTA	Trauma- RTA	Active age	Male
	Pathological- Diabetic	Trauma- RTA	40–60 years	Female
Malaysia	Pathological- Diabetic and other diseases	Trauma- RTA and industrial accidents	30–40 years	Male	Middle or lower socioeconomic groups
Myanmar	Conflict/war- land mines, gunfire Trauma- RTA	Diabetic and other pathological conditions	20–35 years	Male	Lower socio-economic groups
Nepal	Trauma- RTA and natural disaster	Trauma- Work related accidents Diabetic and other pathological conditions	Active age	Male	Lower socio-economic groups
Pakistan	Conflict/war- land mines, gunfire	Pathological- Diabetic Trauma- RTA	20–45 years	Male/Female
	Pathological- Diabetic	Trauma- RTA
Sri Lanka	Trauma- RTA	Pathological- Diabetic and other diseases Conflict/war- land mines	20–50 years	Male	Middle income groups Principal earner groups
Thailand	Pathological- Diabetic and other diseases	Trauma- RTA and industrial accident	30–45 years Children	Male
	Trauma- RTA	Pathological- Diabetic and other diseases	Middle age (30–50)
Vietnam	Trauma- RTA	Pathological- Diabetic and other diseases	Trauma- active age Pathological- old age (>50 years)	Male

RTA: Road traffic accident, Blank spaces indicate there is no information available from in the transcripts.