Introduction
Assistive devices are external devices that are designed, made, or adapted to assist a person to perform a particular task. Many people with disabilities depend on assistive devices to enable them to carry out daily activities and participate actively and productively in community life.
The Convention on the Rights of Persons with Disabilities, Articles 4, 20 and 26, asks States to promote the availability of appropriate devices and mobility aids and provide accessible information about them (2). The Standard Rules on the Equalization of Opportunities for Persons with Disabilities also call upon States to support the development, production, distribution and servicing of assistive devices and equipment and the dissemination of knowledge about them (23).
In many low-income and middle-income countries, only 5–15% of people who require assistive devices and technologies have access to them (34). In these countries, production is low and often of limited quality, there are very few trained personnel and costs may be prohibitive.
Access to assistive devices is essential for many people with disabilities and is an important part of any development strategy. Without assistive devices, people with disabilities may never be educated or able to work, so the cycle of poverty continues. Increasingly, the benefits of assistive devices are also being recognized for older people as a health promotion and prevention strategy.
BOX 31Nepal
Being able to work again
Community Based Rehabilitation Biratnagar (CBRB) is a nongovernmental organization that has been working in the eastern region of Nepal since 1990. Currently it is working in 41 villages of the Morang District and in Biratnagar Submunicipality, providing rehabilitation services to more than 3000 children and adults with disabilities.
In 1997, CBRB started a small orthopaedic workshop to carry out minor repairs of assistive devices, as many people with disabilities had to travel to the capital or neighbouring India for repairs. Over time, CBRB worked towards establishing a fully equipped orthopaedic workshop. Working in partnership with Handicap International (Nepal) they developed a comprehensive service which included the fabrication, provision and repair of assistive devices. Local people (women and men, with and without disabilities) were trained as technicians in Nepal and India and integrated into the existing CBRB team. CBRB now provides quality orthoses (e.g. calipers, braces, splints), prostheses (e.g. artificial legs and hands) and mobility devices (e.g. crutches, tricycles, wheelchairs) to people living with disabilities in 16 districts of eastern Nepal. CBR personnel, therapists and workshop technicians all work hand-in-hand to enhance the quality of life of people with disabilities.
One of the people to have benefited from the orthopaedic workshop is Chandeswar. He is a rickshaw-puller who worked hard until he suffered an injury and had his left leg amputated. He lost his income because he was no longer able to work as a rickshaw-puller and he lost his savings because he needed to pay for his medical care. Chandeswar was identified by the CBRB team working in his village, who fitted him with a below-knee prosthesis and provided rehabilitation to ensure he was able to walk well with his artificial leg and learn how to pedal his rickshaw again. Now Chandeswar is back pedalling his rickshaw around the busy streets of Biratnagar and making a reasonable living.
Seeing the benefit to people such as Chandeswar, the President of CBRB says: “We were carrying out CBR for many years but since we started providing quality assistive devices we have become more effective, our credibility has gone up and now we have a great acceptance in the community”.
Goal
People with disabilities have access to appropriate assistive devices that are of good quality and enable them to participate in life at home and work and in the community.
The role of CBR
The role of CBR is to work with people with disabilities and their families to determine their needs for assistive devices, facilitate access to assistive devices and ensure maintenance, repair and replacement when necessary.
Desirable outcomes
CBR personnel are knowledgeable about assistive devices, including the types available, their functionality and suitability for different disabilities, basic fabrication, availability within communities and referral mechanisms for specialized devices.
People with disabilities and their families are knowledgeable about assistive devices and make informed decisions to access and use them.
People with disabilities and their families are provided with training, education and follow-up to ensure they use and care for their assistive devices appropriately.
Local people, including people with disabilities and their families, are able to fabricate basic assistive devices and undertake simple repairs and maintenance.
Barriers preventing access to assistive devices, such as inadequate information, financial constraints and centralized service provision, are reduced.
Environmental factors are addressed to enable individuals to use their assistive devices in all locations where they are needed.
Key concepts
Common types of assistive device
Assistive devices range from simple, low-technology devices (e.g. walking sticks or adapted cups), to complex, high-technology devices (e.g. specialized computer software/hardware or motorized wheelchairs). It is helpful to consider this wide variety of assistive devices under different categories.
Mobility devices
Mobility devices assist people to walk or move and may include:
wheelchairs
tricycles
crutches
walking sticks/canes
walking frames/walkers.
Mobility devices may have specialized features to accommodate the needs of the user. For example, a person with cerebral palsy may require a wheelchair with trunk/head supports to ensure he/she is able to maintain a good sitting position. The WHO guidelines on Provision of manual wheelchairs in less resourced settings (35) are a useful reference for those people involved in the design, production and distribution of wheelchairs.
Positioning devices
People with physical impairments often have difficulty maintaining good lying, standing or sitting positions for functional activities and are at risk of developing deformities due to improper positioning. The following devices can help overcome some of these difficulties:
Prosthetics, orthotics and orthopaedic shoes
These are usually custom-made devices which replace, support or correct body parts. They are designed, manufactured and fitted in specialized workshops or centres by trained prosthetic/orthotics personnel and include:
prostheses, e.g. artificial legs or hands
orthoses, e.g. spinal braces, hand/leg splints or callipers
orthopaedic shoes.
Daily living devices
These devices enable people with disabilities to complete the activities of daily living (e.g. eating, bathing, dressing, toileting, home maintenance). There are many examples of these devices, including:
adapted cutlery and cups
shower seats and stools
toilet seats and frames
commodes
dressing sticks.
Vision devices
Low vision or blindness has a great impact on a person's ability to carry out important life activities. A range of devices (simple to complex) can be used to maximize participation and independence, including:
large print books
magnifiers
eyeglasses/spectacles
white canes
braille systems for reading and writing
audio devices, e.g. radios, talking books, mobile phones
screen readers for computers, e.g. JAWS (Job Access with Speech) is a screen reader programme.
Hearing devices
Hearing loss affects a person's ability to communicate and interact with others; it can impact on many areas of development, e.g. speech and language and restricts educational and employment opportunities, resulting in social discrimination and isolation. Devices include:
hearing aids
headphones for listening to the television
amplified telephones
TTY/TTD (telecommunication devices)
visual systems to provide cues, e.g. a light when the doorbell is ringing.
BOX 32Papua New Guinea
Top of the class
Anna is a mother who lives in East Sepik province of Papua New Guinea. Her daughter Koris was born deaf. Anna was very determined to send her daughter to school and, through a CBR worker trained by Callan Services for Disabled Persons (a national nongovernmental organization), Anna became aware of a nursery school for deaf children. Before attending this school, Callan Services arranged for the provision of hearing aids; ear mould impressions were taken for Koris and when the hearing aids were ready to be fitted she was sent to an audiologist in Port Moresby. Koris started attending school and also began learning sign language. With the help from assistive devices and with the support of her teachers, Koris soon became one of the top pupils in her class.
Communication devices
Augmentative and alternative communication devices can assist individuals who have difficulty understanding and producing speech. They are provided to support speech (augmentative), or to compensate for speech (alternative). Devices include:
communication boards with pictures, symbols or letters of the alphabet
request cards
electronic speech output devices
computers with specialized equipment and programmes.
Cognitive devices
Cognition is the ability to understand and process information. It refers to the mental functions of the brain such as memory, planning and problem-solving. Brain injuries, intellectual impairment, dementia and mental illness are some of the many conditions that may affect an individual's cognitive ability. The following devices can assist individuals to remember important tasks/events, manage their time and prepare for activities:
Selection of assistive devices
Appropriate technology
Many types of technology are not suitable for rural/remote areas and low-income countries. However, “appropriate technology” is designed with consideration given to the environmental, cultural, social and economic factors that influence communities and individuals. Appropriate technology meets people's needs; it uses local skills, tools and materials and is simple, effective, affordable and acceptable to its users. Assistive devices are technologies that must be carefully designed, produced and selected to ensure they meet these criteria.
BOX 33India
Wearing the same shoes
The Assisi Leprosy and CBR programme in Andhra Pradesh, India provided sandals made of black microcellular rubber to people with leprosy who had lost sensation in their feet and were at risk of foot ulcers. It became obvious that many people who were provided with these sandals did not use them. After talking with these people, it was discovered that by wearing the sandals they were subject to social stigma – the black sandals had become easily identifiable in the community as shoes that only people with leprosy wore. As a result the programme decided to use sandals available from the local market, modifying them as necessary to suit the requirements of people with leprosy. People began wearing the footwear as there was little visible difference between their sandals and those that other community members wore.
Assessment
Assistive devices need to be carefully selected and often specially made and fitted to ensure they meet the individual's needs. Poor selection and design can lead to many problems including frustration, discomfort and the development of secondary conditions. For example, it may be common practice in some countries to distribute donated or second-hand wheelchairs on a large scale. While this may have benefits, it also has the potential to cause harm to users, e.g. the provision of a wheelchair without a cushion to a person with a spinal cord injury may cause a potentially life-threatening pressure area (see Prevention element).
Comprehensive assessment is necessary to ensure assistive devices meet the needs of individuals within their homes, schools and work and community environments. A comprehensive assessment might include a medical history, a review of current function, individual goals, an evaluation of existing assistive devices and a physical examination. The approach to assessment should be multidisciplinary where possible and include a wide variety of people, such as people with disabilities, family members, therapists, technicians, teachers and CBR personnel.
Use of assistive devices
Barrier-free environments
Many people use their assistive devices in different places and it is important to ensure that all environments are barrier-free in order for someone to achieve maximum function and independence. For example, a young woman using a wheelchair must be able to use it to enter/exit her home, move freely within her home and access important areas (e.g. the bathroom), travel within her community and access her workplace.
Adaptations/modifications to the physical environment include installing a ramp where there are steps, widening a narrow doorway, reorganizing furniture to increase the amount of space for movement. It is also important to consider other aspects of the environment, e.g. attitudes and support systems, which can also influence a person's ability to use the device. For example, a young boy who uses a communication board instead of speech will need to use his board both at home and at school, so it is important that family members, schoolteachers and friends are positive, willing and able to use this device with him.
When considering environmental modifications, particularly within the community, it is helpful to consider “universal design” (36). Universal design means designing products, environments, programmes and services to be usable by all people (2), both with and without disabilities.
BOX 34Viet Nam
Bridging the community
In a village in the Thai Binh district of Viet Nam, CBR volunteers motivated community members to improve the local bridge so that people using wheelchairs as well as others could pass over it comfortably.
Suggested activities
Train CBR personnel
CBR personnel require training on assistive devices to ensure that they are able to provide accurate information, referral and education. Training may be specific, or it may be part of a course on rehabilitation. CBR personnel need knowledge about:
the common types of assistive device;
the purpose and function of assistive devices;
which basic devices can be prepared in the community, e.g. crutches;
where specialized devices, e.g. prostheses and hearing aids, are available;
referral mechanisms, to enable access to specialized devices;
the funding options available for people who are unable to afford devices.
Practical training is also essential, particularly for CBR personnel who work in rural/remote areas, to ensure they can produce basic assistive devices and develop the skills and confidence to work directly with individuals who need the devices. For example, CBR personnel may need to:
show a family how to build a wooden chair with a strap to enable a child with poor balance to sit upright;
show a family how to build parallel bars to enable walking practice at home;
show a family how to make a simple walking stick for a person recovering from a stroke to assist her/him in walking;
teach a child with cerebral palsy, with no speech or coordinated hand movement, how to use a pictorial communication board using her/his eyes;
provide instruction to a blind person on the use of her/his white cane.
BOX 35Indonesia
Information where it's needed
The CBR programme in South Sulawesi, Indonesia, prepared an Assistive Device Resource Sheet listing the main service providers in the province who are able to supply and repair devices. This resource sheet is distributed to all CBR personnel, ensuring accurate information is always available for people with disabilities living in villages.
Build capacity of individuals and families
CBR personnel need to work closely with people with disabilities and their family members to ensure that they are:
aware of the different types of assistive device and how these can assist individuals to achieve independence and participation;
involved in decision-making regarding the selection and design of assistive devices – providing opportunities for people to see and try assistive devices will assist them to make informed decisions;
able to use their assistive devices properly and safely and are able to perform repairs and maintenance to ensure long-term use;
able to give feedback to referral services about any difficulties experienced so that adjustments can be made and different options considered.
This health component highlights the fact that self-help groups enable people to share valuable information, skills and experiences. Self-help groups can be particularly beneficial when someone has limited access to rehabilitation personnel. Self-help groups can support individuals to adjust to newly acquired assistive devices, educating them on their care and maintenance and can provide advice on self-care, e.g. prevention of secondary complications and how to achieve optimum function.
Train local artisans
It is unrealistic to expect people living in rural areas to travel to specialized centres to have their devices repaired and many people stop using their devices when they experience problems. Local artisans can be trained to make small repairs to assistive devices such as orthoses, prostheses and wheelchairs, e.g. repair orthoses by replacing straps, screws or rivets. CBR programmes can identify local artisans and facilitate this training in partnership with technicians.
Assistive devices such as walking sticks, crutches, walking frames, standing frames and basic seating can also be produced by local artisans because they are simple to make using locally available materials. CBR programmes can identify local artisans who are interested in producing them and facilitate training.
BOX 36Mongolia
Learning how to make assistive devices
In 2000, the National CBR programme in Mongolia organized a training course for staff working at the National Orthopaedic Laboratory in Ulaan Baatar, to teach them how to make simple splints, seating devices and mobility devices using local materials and appropriate technology. Now, whenever a CBR programme starts in a new province of Mongolia, two local artisans are identified and trained at the National Orthopaedic Laboratory.
Facilitate access to assistive devices
Access to assistive devices may be limited by inadequate information, poverty, distance and centralized service provision. CBR personnel need to work closely with people with disabilities and their families to facilitate access to assistive devices by:
identifying existing service providers – local, regional and national – who produce and/or supply a wide range of assistive devices (basic and specialized);
compiling detailed information on each service provider, including referral mechanisms, costs and processes, e.g. administrative procedures, assessment procedures, number of visits required for measurements and fittings and time for production;
ensuring this information is available in an appropriate format and is communicated to people with disabilities and their families;
identifying funding options for people who are unable to afford the costs associated with assistive devices – CBR programmes can facilitate access to existing government or nongovernmental schemes and can raise their own funds and/or empower individual communities to donate resources;
assisting people to complete relevant administration processes so they can obtain a disability certificate, which in many countries will enable them to access free devices;
partnering with referral centres, local authorities and other organizations to discuss ways to decentralize service provision, e.g. mobile facilities;
providing transport for small groups of people from rural/remote areas to travel to referral centres, ensuring prior arrangements are made with these centres.
providing home or community-based repair services for people living in rural/remote areas, e.g. establish a mobile service or regular meeting point in the community for people needing repairs to their devices.
BOX 37Lebanon
Accessing assistive devices
The national disabled people's organization in Lebanon launched a production unit for wheelchairs and other assistive devices such as crutches, walkers, toilet chairs, orthopaedic shoes and specialized seating systems. They also created five distribution, repair and maintenance workshops around the country to facilitate access to these devices. The production unit and repair workshops employ people with disabilities. The disabled people's organization has also ensured an adequate national budget for assistive devices. CBR programmes can now refer people who need assistive devices to these centres to access assistive devices.
Set up small-scale workshops
When referral services are not available, or barriers such as cost and distance cannot be overcome, CBR programmes can consider setting up and/or supporting a small workshop to meet local needs. Simple devices can be produced by locally trained people. Both the WHO CBR manual (32) and Disabled village children (33) provide information about making assistive devices in the community using local resources.
BOX 38Guinea-Bissau
Finding local solutions
Cumura Hospital in Guinea-Bissau has a small workshop for preparing orthoses and two people with disabilities have been trained as orthopaedic technicians to work here. Finding appropriate materials is often a problem and importing materials is very costly, therefore the technicians try to find local solutions for designs from other workshops. For example they have started to make a leather and plastic splint for persons with foot-drop.
People with disabilities can also be trained to make assistive devices. This can generate income and lead to their recognition as active contributors to their communities, to the development of social networks and ultimately to empowerment.
BOX 39India
Making a small business work
Several CBR programmes in Bangalore, India, identified a group of 10 young women with disabilities. All of these women faced disadvantages and discrimination because they were poor, uneducated, female and disabled – they were all seen as liabilities within their families and communities. In 1998 the 10 women trained as orthopaedic technicians and were provided with a loan from one of the CBR programmes to open a commercial workshop. Life has changed for the women since they started their business (Rehabilitation Aids Workshop by Women with Disabilities). The workshop started making a profit from the second year and by the end of the fourth year they had repaid the whole loan. They extended their business by becoming agents for several major companies that manufactured assistive devices and healthcare products and by establishing links with major private hospitals in the city. The women are now earning good incomes, have good quality of life and are seen as active contributors to their communities. They are married, are assets to their families and are role models for many people with disabilities.
Network and collaborate
In some countries it may not be feasible to establish services that provide a wide range of assistive devices. This may be due to government priorities, limited resources, or small populations. But many assistive devices will be available in neighbouring countries, where they are likely to be cheaper and easier to access than importing them from high-income countries. CBR programmes need to determine what resources are available in neighbouring countries and collaborate with these countries where possible. In addition, CBR programmes need to develop strong links with international and national nongovernmental organizations who are often active in producing and providing assistive devices with a view to the development of sustainable service provision.
Address barriers in the environment
Very often there are barriers in the home, school, work or community environments that make it difficult for people to use their assistive devices. CBR personnel require practical knowledge regarding these barriers so they can work with individuals, family members, communities and local authorities to identify and address them.
