Access to assistive technology for people with intellectual disabilities: a systematic review to identify barriers and facilitators

BACKGROUND

The World Health Organisation has launched a programme to promote Global Cooperation on Assistive Technology. Its aim is to increase access to high-quality affordable assistive products (AP) for everybody in need. People with intellectual disabilities (ID) are a specific group that could benefit from AP, but use less AP compared to their non-intellectual disabled peers.

METHOD

A systematic literature search was carried out to identify barriers and potential facilitators for access to AP for people with ID globally. The search strategy terms were 'Intellectual Disability' and 'Assistive Technology' with the following electronic literature databases PubMed, Embase, ASSIA, Web of Science, Medline, CINAHL complete, PsycInfo, Scopus and ERIC. The quality and relevance of the studies were assessed. Factors associated with access were identified thematically, categorised into barriers and facilitators and mapped into themes.

RESULTS

In all, 22 key studies were retrieved, describing 77 barriers and 56 facilitators. The most frequently reported barriers were related to lack of funding and cost of AP, lack of awareness about AP and inadequate assessment. An increase of knowledge and awareness about AP and the need of AP for people with ID were most often extracted as factors that could potentially facilitate access.

CONCLUSIONS

This review proposes actions linked to the barriers and facilitators that have a particular importance for people with ID to access AP. Yet, only limited research is available describing factors that influence access to AP for people with ID in low and middle income countries and rural areas.

Access to health care for persons with disabilities in rural South Africa

BACKGROUND

Global research suggests that persons with disabilities face barriers when accessing health care services. Yet, information regarding the nature of these barriers, especially in low-income and middle-income countries is sparse. Rural contexts in these countries may present greater barriers than urban contexts, but little is known about access issues in such contexts. There is a paucity of research in South Africa looking at "triple vulnerability" - poverty, disability and rurality. This study explored issues of access to health care for persons with disabilities in an impoverished rural area in South Africa.

METHODS

The study includes a quantitative survey with interviews with 773 participants in 527 households. Comparisons in terms of access to health care between persons with disabilities and persons with no disabilities were explored. The approach to data analysis included quantitative data analysis using descriptive and inferential statistics. Frequency and cross tabulation, comparing and contrasting the frequency of different phenomena between persons with disabilities and persons with no disabilities, were used. Chi-square tests and Analysis of Variance tests were then incorporated into the analysis.

RESULTS

Persons with disabilities have a higher rate of unmet health needs as compared to non-disabled. In rural Madwaleni in South Africa, persons with disabilities faced significantly more barriers to accessing health care compared to persons without disabilities. Barriers increased with disability severity and was reduced with increasing level of education, living in a household without disabled members and with age.

CONCLUSIONS

This study has shown that access to health care in a rural area in South Africa for persons with disabilities is more of an issue than for persons without disabilities in that they face more barriers. Implications are that we need to look beyond the medical issues of disability and address social and inclusion issues as well.

Non-use of Formal Health Services in Malawi: Perceptions from Non-users

BACKGROUND

The study upon which this paper is based was undertaken to understand users' and non-users' perceptions concerning facilitators and barriers to equitable and universal access to health care in resource-poor countries such as Malawi. In this study, non-users of health services were defined as people who were not in need of health services or those who had stopped using them due to significant barriers.

METHODS

A total of 80 interviews with non-users of health services were conducted in Rumphi, Ntchisi, Phalombe and Blantyre Districts of Malawi. Interviews focused on why informants were not using formal health services at the time of data collection. In order to identify non-users, snowballing was used health surveillance assistants, village headmen and community members also helped. One focus group discussion was also conducted with non-users of health services who were members of the Zion Church.

RESULTS

Informants described themselves as non-users of health services due to several reasons: cost of health services; long distances to health facilities; poor attitude of health workers; belief in the effectiveness of traditional medicines; old age and their failure to walk. Others were non-users due to their disability; hence they could not walk over long distances or could not communicate effectively with health providers. Some of these non-users were complete non-users, namely members of the Zion Church and those who believed in traditional medicine, and they stated that nothing could be done to transform them into users of health services. Other non-users stated that they could become users if their challenges were addressed e.g. for those who were non-users of health services due to poor attitudes of health workers, they stated that if these health workers were transferred they would be able to access health services.

CONCLUSIONS

Public health education targeting both health workers and non-users, ensuring a functional outreach program and addressing other health system challenges such as shortage of drugs and human resources would assist in transforming non-users into users of health services.

Psychosocial adjustment to diabetes-related lower limb amputation

AIM

To examine psychosocial adjustment in persons with lower limb amputations related to diabetes.

METHODS

Thirty-eight participants with diabetes-related lower limb amputations, recruited from two limb-fitting centres, completed three psychological self-report assessments: the Trinity Amputation and Prosthesis Experience Scales (TAPES); the Hospital Anxiety and Depression Scale (HADS); and the Amputation Body Image Scale-Revised (ABIS-R).

RESULTS

Over 18% of participants scored above the normal range (> 8) for depression on the HADS and 18.5% scored above the normal range for anxiety. Both depression (rho = 0.75, P < 0.01) and anxiety (rho = 0.62, P < 0.01) scores were significantly associated with body image disturbance, as measured using the ABIS-R. Significant relationships were also observed between body image disturbance and three TAPES subscales measuring psychosocial adjustment [general adjustment (rho = -0.48, P < 0.01), social adjustment (rho = -0.51, P < 0.01), adjustment to limitations (rho = -0.45, P < 0.05)].

CONCLUSIONS

Individuals with diabetes-related amputations may be at elevated risk for psychological distress as a result of their co-morbid medical condition. Regular screening for anxiety and depression and the provision of appropriate follow-up care may therefore be advisable in this population.

Psychological issues in prosthetic and orthotic practice: a 25 year review of psychology in Prosthetics and Orthotics International

In the inaugural edition of Prosthetics and Orthotics International, Fishman identified the psychological sciences as one of six indispensable areas of skill and knowledge in professional prosthetic-orthotic practice. Given the journal's significant role in reporting and developing pertinent research and practice, this review assesses the profile of psychology in prosthetic and orthotic research, as evidenced by the content of Prosthetics and Orthotics International since its inception. A MEDLINE search of the journal's abstracts over a twenty-five year period was conducted using the search terms: 'psychology', 'psychosocial', 'quality of life', 'developmental' and 'coping'. Results of this search are summarised under the following headings: (a) body image; (b) coping and adjustment; (c) developmental issues; (d) psychosocial well-being; (e) quality of life; and (f) psychological factors leading to amputation. On the basis of this review, the authors conclude by highlighting a number of key areas where the psychological aspects of prosthetics and orthotics warrant further investigation and dissemination.

Cross-cultural examination of the tripartite model with children: data from the Barretstown studies

The Positive and Negative Affect Scale for Children (PANAS-C) and the Physiological Hyperarousal Scale for Children (PH-C) were administered to a group of 240 children from European countries to determine their utility in examining the tripartite model of anxiety and depression in a cross-cultural sample. Most of the children (n = 196) had been diagnosed with a medical illness; the remainder were siblings of these youngsters (n = 44). Only slight variations were noted in items between this sample and samples from the United States. Despite these minor differences, 3 distinct scales measuring the positive affect, negative affect, and physiological hyperarousal constructs of the tripartite model were identified. These findings illustrate that the PH-PANAS-C provides a useful measure of the tripartite model in a cross-cultural sample of youth. The findings also demonstrate that the tripartite model is generalizable to a cross-cultural milieu.

Positive meaning in amputation and thoughts about the amputated limb

The majority of research conducted on the aftermath of amputation understandably concerns itself with its most distressing aspects. This research aimed to explore whether and how people think about their amputated limb, and whether and if they considered anything good had emerged from their amputation. One hundred and four (104) people completed the Trinity Amputation and Prosthesis Experience Scales (TAPES) and two open-ended questions. The majority of participants were young and had traumatic amputations. Fifty-six percent (56%) of people thought about their amputated limb. People with bilateral or a trans-femoral amputation were more likely to think about their amputated limb than people with a trans-tibial amputation. Forty-eight percent (48%) considered that something good had happened as a result of the amputation. Furthermore, finding positive meaning was significantly associated with more favourable physical capabilities and health ratings, lower levels of Athletic Activity Restriction and higher levels of Adjustment to Limitation. Future research and clinical implications are discussed.

Psychological adjustment and coping in adults with prosthetic limbs

The potential mediating effects of different coping strategies on the adjustment to living with a prosthetic limb were investigated in 44 adult amputees. Participants completed a questionnaire inquiring about coping, pain, emotional well-being, demographics, and disability-related variables. The coping strategy adopted and the extent of the adjustment to the prosthetic limb varied with age, site of limb loss, and cause of amputation. Furthermore, coping style mediated the adjustment to wearing a prosthetic limb. The results are discussed in terms of future applications and research.

Patients' perceptions of chamba (marijuana) use in Malawi

This study examines the perceptions of the social aspects, triggers, and effects of chamba (marijuana) use among psychiatric patients at Zomba Mental Hospital in Malawi. Focus groups were used to elicit responses from 44 male and 10 female psychiatric patients about their perceptions of chamba use in Malawi. This study provides insight into these patients' perceptions of the triggers and effects of their chamba use, and it has implications for the development of treatment and prevention programs for chamba users in Malawi.

Tropical illness profiles: the psychology of illness perception in Malawi

Psychological and social investigations of tropical diseases can make a significant contribution to understanding and managing many illnesses. One-hundred and seventy-five Malawian university students rated peopled who suffered from AIDS, malaria, schistosomiasis and the 'common cold', on 11 psycho-social dimensions related to illness. Analysis of variance and factor analysis was used to distinguish distinctive illness profiles reflecting perceptions of (people with) these illnesses. Results suggested that infirmity was associated with AIDS and that the seriousness of malaria was minimized. Within a context of many threats to health the importance of distinguishing between serious illnesses is emphasized for effective health promotion interventions.

Effects of unreasonable pay discrepancies for under- and overpayment on double demotivation

The "double demotivation" hypothesis that pay discrepancies decrease work motivation among both lower and higher paid groups was tested in two experiments. In experiment 1, 70 Australian undergraduates received either $1 or $2 to work on an intrinsically rewarding puzzle, with or without knowledge of what amount other participants were receiving. A comparison of participants with a no-payment control showed that participants exhibited significantly reduced intrinsic motivation (seconds spent interacting with the puzzle during a free-choice period) when they knew that they were being under- or overpaid. In experiment 2, 126 occupationally matched Australian workers receiving wages equal to, lower than, or higher than those of counterparts reported their level of job satisfaction and whether they would stay on the job, change jobs, or retire, if given the financial opportunity. Compared with equitably paid workers, employees who felt they were being under- or overpaid reported lower job satisfaction and greater readiness to change jobs. The results provide experimental support for double demotivation, which is relevant not only to international development cooperation but also to Western enterprise bargaining, merit pay, and minority groups in the multicultural workplace.

Identifying problems in community health promotion: an illustration of the Nominal Group Technique in AIDS education

Recognition of the extent and consequences of HIV/AIDS in Africa has resulted in many large scale health promotion programmes. These programmes usually provide information about how to avoid contracting HIV as well as information to dispel false beliefs about the virus. However there also exist anti-health promotion ideas about HIV/AIDS which often challenge the very premises on which health promotion messages are based. Such anti-health promotion ideas may represent reassuring benefits and these are likely to vary not only across cultures but also between different communities and 'at risk' groups within the same culture. The Nominal Group Technique (NGT) is a participative exercise which can be used with small groups to achieve a consensus concerning which anti-health promotion ideas are most influential in terms of encouraging people to ignore health promoting messages. The application of the NGT is illustrated with a group of Malawian students.

Towards AIDS prevention and education at the University of Malawi

It is important to develop community orientated approaches to health promotion. Malawi has one of the highest rates of AIDS/HIV infection and one of the lowest percentages of students in tertiary education, in the world. We surveyed the opinions of 175 undergraduate university students on developing prevention and education regarding HIV/AIDS. Descriptive statistics, analysis of variance and factor analysis revealed several important findings: there were no consequential differences between the responses of male and female students; information on self protection was rated as most important for AIDS/HIV education; the primary factor for AIDS/HIV prevention also related to protection, but this was in conjunction with a desire for "sex-perpetuation". These findings should contribute to the development of health promotion initiatives, directed at AIDS/HIV, which reflect the values and concerns of the university student community. Such an approach acknowledges the role of students as a major 'stakeholder' in the university community, rather than dissempowering them as simply the recipients of 'appropriate AIDS/HIV prevention/education'.

Attributions for admission to Zomba Mental Hospital: implications for the development of mental health services in Malawi

Within Malawi, as in many other African countries, a variety of traditional and modern attributions exist regarding the cause of a person's mental disturbance, or their admission to a 'mental' hospital. It is argued that a good mental health service should consider the beliefs of the patients it seeks to serve. Consequently we studied 103 consecutive admissions to Zomba Mental Hospital in order to find out how patients explained their own admission to the hospital. Traditional attributions were the most common, followed by medical and then psychological attributions. Some patients explained their admission to the hospital by combining traditional, medical or psychological ideas. Content analysis of traditional attributions identified examples of "Tropical Tolerance" and the "Pull Down" phenomenon. The possible interactive nature of traditional, medical and psychological processes is discussed and it is suggested that traditional healers should be incorporated into 'modern' Malawian mental health services.

Managing the AIDS crisis in Africa: in support of pluralism

Although substantial evidence is now accumulating that some African peoples readily accept advice and help about health from both modern medical and traditional sources, this has not yet happened with--what is arguably the major health problem in many part of Africa--AIDS. We asked 175 of Malawi's undergraduates what sources they judged to be credible with regard to information on preventing and clinically managing AIDS. While traditional healers were seen on average to be less credible than modern health professionals (doctors and nurses), there was no correspondence between credibility of traditional healers and modern health professionals. Thus a strong belief in the credibility of modern health professionals was not associated with low credibility ratings for traditional healers. Our findings provide further support for "tropical tolerance", especially as regards a pluralistic (modern and traditional together) approach to the prevention of AIDS. Given the over-stretched health services in Malawi and many other African countries, a pluralistic approach to AIDS prevention could be a credible and economic use of indigenous human resources.

Palliative versus curative beliefs regarding tropical epilepsy as a function of traditional and medical attributions

Although epilepsy may be successfully managed with appropriate medication, in Africa epileptics are often vilified, sometimes because of traditional beliefs about the illness. We investigated the strength of beliefs which 112 rural Malawians held regarding traditional and medical explanations for the cause, treatment and cure of epilepsy. Those who believed in traditional causes of epilepsy also endorsed traditional treatment for it, though they did not see such treatment as curative. Those who believed in a medical treatment, did however see such treatment as curative. Knowledge of a local medical facility for the treatment of epilepsy was also positively related to the belief that epilepsy is curable. The ability of people to simultaneously hold medical and traditional beliefs about epilepsy was noted.

Sustaining health service developments in the 'Third World'

An increasing number of 'third world' health development projects are proving to be unsustainable once foreign aid has been withdrawn. It is argued that this is partly due to the fact that such projects usually deliver health care free of charge rather than allowing communities to incorporate the costs of health care into their local economies. There should be more emphasis on health development projects paying for themselves from the outset. Such projects might also incorporate the extant community based infra-structure of traditional medicine through direct collaboration with its practitioners.

Managers as social surgeons

Deals with the Health Service manager's problems of pruning staff in NHS Trust applications. Compares handling staff with a surgeon handling patients pre-, during and post-operations. Concludes that the Health Service manager must consider the key issues of communication, involvement, unambiguity and encouraging the free expression of dissent.

Psychological aspects of dietary weight loss and medication with the atypical beta agonist BRL 26830A in obese subjects

Psychological aspects of dieting, including hunger and satiety sensations were explored in obese subjects during a placebo-controlled trial of the weight reducing potential of BRL 26830A, a thermogenic beta-3-agonist drug. Successful weight loss was associated with a reduction in the severity of reported depression. The initial degree of emotional disturbance and level of learned resourcefulness appeared to influence the subsequent weight lost. Subjects described few specific hunger and satiety sensations and these sensations did not generally alter during the trial. BRL 26830A, which promoted weight loss, did not significantly influence hunger and satiety sensations and was not associated with emotional disturbances during dieting. With BRL 26830A there was a reduction in the reported somatic symptoms of anxiety which was not apparent on placebo. These results suggest that the subjects' initial psychological state influences outcome when dieting and also that dynamic changes in psychological parameters occur with successful weight loss. Further, BRL 26830A had no effect on appetite and no adverse influence on the psychological functions tested during this study.