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Skip to 0 minutes and 12 secondsDOROTHY BOGGS: Throughout the week, we have highlighted the different ways that disability and poor health are linked through the varied health and disability case studies, and specifically in the malnutrition case study in the previous step. We will now explore the broader links among health, disability, and poverty. It is well-known and well-documented through research that there is a vicious cycle between poverty and disability. This means that people experiencing poverty are more likely to become disabled, and people with disabilities are more likely to be poor.

Skip to 0 minutes and 47 secondsThis pathway can be influenced by many factors, such as health; ageing; social factors, such as family support and access to community activities; the environment in which people live, such as situations of conflict and rural versus urban areas; and access to services, including the availability of appropriate services. As illustrated throughout the case studies and explained by Myroslava and Hannah earlier in the week, it is also well researched that people with disabilities might experience poor health, and that people with poor health might be at greater risk of disability. Once again, these pathways can be influenced by many other factors, such as already living in poverty, ageing, social and environmental factors, and access to services.

Skip to 1 minute and 50 secondsAs mentioned earlier, the pathways among poverty, disability, and health are often interrelated, complex and influenced by a variety of factors. So how might all these linked and complex pathways impact on whether a person with a disability is included or excluded from their community and society? And, in line with the United Nations Convention on the Rights of Persons with Disabilities, how do we support inclusion for everyone? Let's discuss these diverse and interconnected pathways using a more dynamic concept, extending the concept of a cycle to that of a disability spiral. To help us better understand the disability spiral, let's consider a young adult woman with an intellectual disability for example.

Skip to 2 minutes and 40 secondsImagine that she might live in a high income country or in a lower middle income country, since some of these factors are universal, as we will explore more now. This individual might experience poor health due to a higher risk of injury or of acquiring either communicable or noncommunicable diseases. This could likely be further impacted by poor access to health care as a result of various attitudinal and other access barriers, like those that we explored earlier in the week. This could lead to increased risk of poverty, for example if the woman is not well enough to work and contribute to her family's income.

Skip to 3 minutes and 23 secondsIn addition, the barriers to health services she faces and the cost of those services themselves may mean she and her family would have less to spend on other essential areas, such as food or education. These risks would only continue to increase and potentially worsen over time as the woman ages. Therefore, this woman with an intellectual disability might experience further social exclusion and access barriers over time. All of these factors listed are interlinked and mutually reinforcing, creating a downward spiral of exclusion for this woman with a disability, and decreasing her overall wellbeing. But what if the situation was changed?

Skip to 4 minutes and 13 secondsWhat if by improving access to health and rehabilitation services the cycle could be broken, reversing the spiral towards inclusion and improved well-being? Let's explore this by reviewing the same example of a woman with an intellectual disability. Let's assume that through a newly-implemented social protection and disability awareness health training programme, with barriers to health care removed, she now has better access to health care and rehabilitation services, resulting in improved health, self-care and social skills, along with safer environmental mobility. Through a job skills training programme, she is now able to have a job, earning an income. This might lead to increased community support through socialising with peers and also with her family, since she is now contributing to household income.

Skip to 5 minutes and 9 secondsOver time, this would lead to increased inclusion in her social settings and home environment resulting in an overall improved well-being. Therefore, through better access to health and rehabilitation services, these similar interlinked factors can mutually reinforce one another in an upward spiral of inclusion for this woman with a disability. How do you think the disability spiral could be applied to our three case studies? Let's now explore the disability spiral further through one of our case studies. For this example, let's think about our third case study, Joseph, an older male from Northwest Cameroon, who is waiting for a referral for a free cataract operation and has age-related hearing loss.

Skip to 5 minutes and 59 secondsLiving in Cameroon, a lower middle income country, Joseph lives in a resource poor setting, and is ageing, which places him at a higher risk of injury and disease, especially with his vision, hearing, and cognition. These factors have resulted in poorer health for Joseph. He is currently waiting for a referral for a cataract operation and has age-related hearing loss, which impacts his daily functioning. These impairments place him at a higher risk of disability with increased risk of poverty and exclusion from his home and community. As exhibited through Joseph's case study, all of these factors are interlinked and mutually reinforcing, creating a pathway of a downward spiral. Now let's consider if Joseph's situation was changed.

Skip to 6 minutes and 51 secondsFirst, Joseph has cataracts which impair his vision and also has age-related hearing loss. He now also has difficulties with his balance, so he has to walk with a walking frame with wheels, and is forgetful often missing his medication times. His impairments lead to difficulty navigating safely in his home and community environments. Joseph is disabled by these factors. However, he is now off the waiting list for his surgery and successfully has his cataract operation. While in the hospital, he receives rehabilitation services, so he completes exercises that decrease his balance difficulties and learns compensatory strategies for his hearing loss and cognitive difficulties. He now has improved health and mobility and is able to safely attend social activities in the village.

Skip to 7 minutes and 46 secondsThis leads to increased inclusion in his village, resulting in an overall improved well-being. Therefore, similar interlinked factors naturally reinforced an upward spiral of inclusion for Joseph.

Skip to 8 minutes and 2 secondsBringing it all together, we have now explored the many factors that influence the pathways among poverty, disability and health that can either result in a downward spiral towards exclusion, which further increases access barriers and risks; or an upward spiral towards inclusion, the ultimate aim of disability inclusive policy and programming, which exemplifies the UNCRPD and importance of human rights of access and inclusion for all. What are your thoughts about the disability spiral? Can you apply the disability spiral concept to our two other individual case studies, Santhi and Maria? Perhaps you have experiences that relate to the downwards or upwards disability spiral.

Skip to 8 minutes and 45 secondsShare your thoughts and reflections in the comments area below, and in the following step you will take a quiz covering the main topics that we discussed this week.

Disability spiral

Following the case studies looking at longer term health conditions and disability, Dorothy Boggs (LSHTM) explores the broader links among health, disability and poverty and presents the ‘Disability spiral.’

In this video, she describes the wider pathways between poor health and disability and how this is impacted by poverty. The concept of the ‘Disability spiral’ is presented as a way to conceptualise and visualise the pathways among various factors impacting health, disability and poverty. She presents examples of the downwards and upwards Disability spiral through case stuy examples of a woman with an intellectual disability and Joseph, the third individual case study who is an older man from Cameroon.

What are your thoughts about the Disability spiral? Can you apply the disability spiral concept to our two other individual case studies, Santhi and Maria’? Perhaps you have experiences that relate to the downwards or upwards disability spiral? Share your thoughts and reflections in the comments area below and, in the following Step, you will take a quiz covering the main topics that we discussed this week.

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This video is from the free online course:

Global Health and Disability

London School of Hygiene & Tropical Medicine

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