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What is the relationship between impairments and disability?

Describes the relationship between impairments and disability, as mediated by personal and environmental factors
HANNAH KUPER: So today, we’re going to talk a little bit more about the relationship between disability and impairment. Now, I want you to think of a person who you consider to have a disability. It could be a friend. It could be a relative. It could be a colleague. It could be yourself. For me, I’m thinking of a woman who I grew up with who has Down’s syndrome. Now, I want you to think about that person doing everyday normal activities– going to the shop, having a job, meeting friends, or even going to the doctor. What kind of difficulties do you think that person would face in those day to day activities?
And of it, what do you think is related to their impairment, and what is about other things, like discrimination, poverty, or even the lack of ramps? So if I think about my friend who has Down’s syndrome and imagine her going to see a doctor, she may find it difficult to understand some of the things that the doctor’s explaining because of her intellectual impairment. But that also depends on the attitude of the doctor. If the doctor takes time to explain things simply, to use different kinds of ways of conveying the message, like through pictures or photos, or else gives lots and lots of time for her to ask questions and give responses.
So even just thinking about that interaction, the experience of disability, of exclusion is not just about impairment, but it’s about everything else that goes along with it, about discrimination, attitudes, and so on. And so this relationship between disability and impairment is now going to be considered by a couple of different health and rehabilitation practitioners using their different experiences.
ALLEN FOSTER: Well, if somebody will come and they would say, doctor, I can’t see. Basically, you want to know how much can they see, are they totally blind, what can they do? So you want to actually assess their functioning. Do they have problems walking about by themselves? Can they work? If they were a driver, can they still drive a car? Et cetera. So having done that, you then want to know why can’t they see. The good news is that the main cause of blindness in the world is cataract. And that’s treatable. So someone who comes to you, and they’re visually impaired, not functioning very well, you can actually offer them cataract surgery.
And if they agree to cataract surgery, then actually within two or three days, their sight is restored and they can go back to normal life, normal functioning. They can be walking around, working again, even driving a car. So that was the good news of working in Africa. When somebody comes with irreversible blindness, then it’s a real frustration, because you’re actually there to try and help people see again. Maybe the person’s got glaucoma and they’re totally blind. And you can’t do anything to help them see. But it’s actually very important that you realise that they’ve still come for your help. And that they still need help.
So although you can’t restore their sight, you do want to try and help them with mobility skills, so that they can walk around again or daily life skills like eating and washing. And you as a doctor may not be in a position to do that, but it’s very important that you know where those rehabilitation services are. And the patient will be looking to you for advice. And they’ll be trusting and listening to you.
So it’s important that you don’t just say, ‘oh, I can’t do anything for you because you’re blind’, but rather you say, ‘I’m sorry I can’t do an operation to make you see, but we can help you with rehabilitation services that will improve your quality of life, improve your functioning, improve your participation back into society.’
DARREN BROWN: Because HIV is obviously now a long-term chronic health condition, with people living normal life expectancies, people living with HIV can experience either worsening of existing disabilities or new disabilities. And these new disabilities can come from either HIV itself, ageing, or the side effects of antiretroviral therapy. Disability in the context of HIV can actually be episodic or fluctuating, where the disability experienced by people living with HIV can be unpredictable. And therefore they can have periods of wellness, or periods of illness, that you may not be able to predict. Growing older with HIV and experiencing multimorbidity and disability also can create frailty for people living with HIV.
And rehabilitation, and particularly physiotherapy, is incredibly important, not only for preventing, managing, reversing frailty experienced by people living with HIV. It’s very easy for a physiotherapist to focus on the functional element of rehabilitation and measuring that disability from a functional capacity perspective. However, for people living with HIV, stigma can be a huge challenge. And because of that, that can impact not only on participation, but ultimately activity, and could even impact on things like impairment, for example, pain. So therefore, as a physiotherapist, I have to be respectful and understand how stigma can impact on the disability experienced by people living with HIV.
I may not be able to change that stigma, but by understanding and being sensitive to that, I can hopefully provide interventions that are addressing the unique needs of the individual that I help. Globally, there is a lack of information about how disability and HIV interact, particularly from an episodic disability framework perspective of the fluctuating and episodic nature of disability experienced by people living with HIV.
MARK SPRECKLEY: I’m researching the impact of hearing loss and the use of hearing aids on adults living in Guatemala. This has particular interest to me because I’m someone who wears hearing aids. I have a moderate level of hearing loss. My research in Guatemala demonstrated that amongst those adults, hearing loss caused issues with communication at school, at work, and the ability to communicate with family and friends. It demonstrated that it increased the likelihood or chances of symptoms of depression. It caused greater levels of socioeconomic problems and also poverty. It was linked with activity participation restriction. And socially, it was found very difficult.
At the same time, as soon as we provided hearing aids, that improved the quality of life for our cases and at the same time demonstrated an improvement in their mental health and well-being, as well as the ability to communicate and socially interact.
HANNAH KUPER: So we’ve now heard from different health practitioners and rehabilitation specialists about the links between disability and impairment. I hope that you found it interesting. And remember to do contribute to the conversations that are happening.

In this video, we will hear from a range of health and rehabilitation professionals, who will discuss the need to understand the relationship between “impairments” and “disability” in their work. They will share their experiences in terms of acknowledging the additional needs of their patients and clients beyond the direct services they are able to provide, and being aware of the difference between impairment and disability.

Professor Hannah Kuper (LSHTM) introduces the video, providing you with an example of a person she knows with a disability, to help you start thinking about the difference between “impairments” and “disability” as concepts.

Professor Allen Foster (co-director of the International Centre for Eye Health at LSHTM and Public Health Ophthalmologist) continues with an example of eye health service provision in Africa. Darren Brown, Specialist Physiotherapist in HIV, Disability and Rehabilitation provides a case study on impairment and disability in the context of a long term health condition; and lastly LSHTM Doctoral Student in Public Health, and physiotherapist, Mark Spreckley concludes with an overview of his recent research on hearing impairment and disability in Guatemala.

Use the comments section below to share your thoughts after watching the video. Particularly if you are a health or rehabilitation professional yourself, have you ever stopped to think about the relationship between a patient’s impairment, and the broader concept of disability?

And, what about thinking about the link between other health conditions and disability. For example, is there a need to think about disability in terms of the recent epidemics of Ebola and Zika virus? What about common non-communicable diseases (NCDs), like diabetes?

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Global Health and Disability

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