Question & problem
People with disabilities are at a higher risk of developing poorer health outcomes, due to their primary underlying health conditions or impairments, and unmet health needs due to access and attitudinal barriers to health services and quality care. Evidence suggests that when seeking healthcare or accessing healthcare services, people with disabilities are more likely to find the health care professional’s skills and confidence to be inadequate to meet their health needs. Moreover, healthcare professionals’ unfamiliarity with disability may lead to negative attitudes and stigma towards people with disabilities. Consequently, contributing to delayed diagnosis and treatment, lower quality of care and ultimately poorer health outcomes. As specified in the UN Convention on the Rights of Persons with Disabilities (UNCRPD), people with disabilities have the rights to the same high quality of care as all, therefore, it is imperative to improve healthcare professionals’ competency, confidence, and attitudes in treating patient with disabilities.
Quote
Recommendations
Key recommendation
Action
- The Government or related ministry must work with key stakeholders (e.g. people with disabilities, DPOs, healthcare professionals and universities) from the initial planning of the intervention. Subsequently, the current state or availability of physical infrastructure (i.e., classrooms, meeting rooms, internet connections) should be evaluated for their readiness to implement healthcare professionals’ training.
- Exploring the potential use of internet-based platforms for training and anti-stigma campaigns. Providing accessible practical tools or guidebooks for training and for regular practice.
Key recommendation
Action
- Conduct periodical training on disability-inclusion for those working in primary healthcare services with incentives given to health professionals that takes part in disability training to facilitate motivation e.g. professional credits or economic incentives.
- This training should be a multi-dimensional programme that can benefit professionals having varying levels of expertise. Knowledge updates should include how to utilise available tools to guide diagnosis of people with disabilities, e.g. the use of the Leprosy toolkit or the WHO – Mental health Gap Action Programme (mhGAP).
Key recommendation
Action
Training to increase knowledge and skill about disability must involve direct contact with people with disabilities, caregivers, and organisations that represent people with disability. Evidence shows that this approach helps healthcare professionals in understanding the health needs of people with disability when accessing healthcare services. Therefore, healthcare professionals can tailor their care to the needs of people with disabilities.
Key recommendation
Action
- The curriculum of professional training for healthcare workers, i.e., medical school, nursing school, etc, should include and explore local cultural understandings of disability. Moreover, encountering people with disability in clinical settings will facilitate the contextual understanding of issues in disability and skills for cultural competency.
- Importantly, frameworks such as the International Classification for Function (WHO-ICF) should be introduced to future healthcare professionals early in their professional training.
Key recommendation
Action
- When available use validated tools to measure the desired outcome objectively. Short-term pre-and post-test outcomes from an intervention should be compared with a longitudinal observation. Furthermore, when designing an intervention, it would be more practical to specify the type of disability or impairment (i.e., mental health, neurodevelopmental disabilities, etc) when providing guidance on how to target needs.
- Future research should also include the cost-effectiveness of interventions, as it imperative that an effective intervention is also feasible in limited resource settings.
Challenges
Challenge #1: People with disability are twice as likely to find healthcare providers inadequate levels of skills and confidence to meet their health needs.
- There is a lower quality of care for people with disabilities when associated with healthcare professionals such as doctors, nurses, or other health practitioners, that lack the skills or competency to recognise disability, and the confidence to interact with people with disability in healthcare settings. Furthermore, contributing to delays in diagnosis and low adherence to treatment.
- In many countries, primary healthcare centres (PHC) serve as the entry point for healthcare services. In Bangladesh, India, and Indonesia, a PHC can serve from 6000 to 30000 people. Therefore, it is important for the first line of healthcare to have the ability to detect disabilities, so that people with disabilities can receive targeted support or receive a referral to specialist care when required.
- Building capacity of primary healthcare professionals and community healthcare workers through direct contact training and interventions should be prioritised, especially in settings or countries where primary healthcare serves as the first line of healthcare access.
Challenge #2: Stigma towards people with disabilities from healthcare professionals contributes to poorer health outcomes for people with disability.
- Being unfamiliar with disability can lead to negative attitudes and stigma toward people with disability. There is strong evidence that stigma or prejudice toward people with disability in healthcare settings by providers can induce an unwelcoming environment. Negative attitudes and stigma are a barrier to equitable healthcare and can therefore contribute to poorer health outcome. It can also be life threatening, as it may lead people with disability to delay seeking care and low adherence in treatment. Yet, it is rare for healthcare services to include stigma reduction strategies as part of their healthcare delivery or evaluation.
- Therefore, it is important to collect relevant data using inclusive and participatory approaches to guide intervention designs and avoid making assumptions on the magnitude of stigma and discrimination and whom it affects.
Challenge #3: Historically, teaching healthcare professionals about disability has not been a priority
- In many countries, knowledge or skills with regard to disability have not been part of medical or nursing schools’ curriculum, and concepts of disability are only discussed comprehensively in specialist training.
- Current evidence shows that only medical schools in high income settings have introduced specific disability-related information or modules in their professional training curricula.
Challenge #4: There is very limited evidence available on the long-term effects of interventions targeting improvements of healthcare professionals’ knowledge and skillsets to treat people with disability
- Current evidence is limited to measuring short-term effectiveness of interventions. Moreover, existing methodologies focus on knowledge, and few explore how to deal with the complex nature of stigma.
- Most intervention studies used their own designed pre- and post- intervention tools to evaluate the effectiveness of disability training on health professionals, showing that there is a need to develop a common standardised tool. Evidence suggests that the best way to objectively measure effectiveness of training is through self-reported satisfaction of care from people with disabilities, caregivers, or representative organisations.
- It is important that interventions are both effective and efficient, especially in settings where resources are limited. However, there is very little evidence on the cost-effectiveness of effective disability training or capacity-building initiatives for healthcare professionals.
Finding the answers
A systematic review of reviews was conducted. We examined systematic, narrative, scoping and other types of reviews on the topic of ‘what interventions are effective to improve healthcare professionals’ skills and confidence in treating patients with disability as well as to reduce negative attitudes and stigma in healthcare settings’. The definition of healthcare professionals’ skills in this brief was for them to be able to reasonable identify a person with disability, to be able to interact with patients’ with disabilities and to understand and apply the framework of the International Classifications of Functioning (WHO-ICF). This brief synthesized its recommendation from 8 reviews that investigated interventions aimed towards enhancing the skills and knowledge of healthcare professionals on disability and interventions to reduce stigma and negative attitudes of healthcare professionals toward people with disability. Moreover, this includes review of trainings methods, curriculum change, policy adjustments, and assessments of barriers and enablers if an intervention would take place. All recommendations are based on literature coming from HICs and LMICs.
Recommendations & actions
Key recommendation
Action
- The Government or related ministry must work with key stakeholders (e.g. people with disabilities, DPOs, healthcare professionals and universities) from the initial planning of the intervention. Subsequently, the current state or availability of physical infrastructure (i.e., classrooms, meeting rooms, internet connections) should be evaluated for their readiness to implement healthcare professionals’ training.
- Exploring the potential use of internet-based platforms for training and anti-stigma campaigns. Providing accessible practical tools or guidebooks for training and for regular practice.
Key recommendation
Action
- Conduct periodical training on disability-inclusion for those working in primary healthcare services with incentives given to health professionals that takes part in disability training to facilitate motivation e.g. professional credits or economic incentives.
- This training should be a multi-dimensional programme that can benefit professionals having varying levels of expertise. Knowledge updates should include how to utilise available tools to guide diagnosis of people with disabilities, e.g. the use of the Leprosy toolkit or the WHO – Mental health Gap Action Programme (mhGAP).
Key recommendation
Action
Training to increase knowledge and skill about disability must involve direct contact with people with disabilities, caregivers, and organisations that represent people with disability. Evidence shows that this approach helps healthcare professionals in understanding the health needs of people with disability when accessing healthcare services. Therefore, healthcare professionals can tailor their care to the needs of people with disabilities.
Key recommendation
Action
- The curriculum of professional training for healthcare workers, i.e., medical school, nursing school, etc, should include and explore local cultural understandings of disability. Moreover, encountering people with disability in clinical settings will facilitate the contextual understanding of issues in disability and skills for cultural competency.
- Importantly, frameworks such as the International Classification for Function (WHO-ICF) should be introduced to future healthcare professionals early in their professional training.
Key recommendation
Action
- When available use validated tools to measure the desired outcome objectively. Short-term pre-and post-test outcomes from an intervention should be compared with a longitudinal observation. Furthermore, when designing an intervention, it would be more practical to specify the type of disability or impairment (i.e., mental health, neurodevelopmental disabilities, etc) when providing guidance on how to target needs.
- Future research should also include the cost-effectiveness of interventions, as it imperative that an effective intervention is also feasible in limited resource settings.
Policy priorities
As highlighted above there is a need for capacity building on disability knowledge and monitoring skills for healthcare professionals across diverse healthcare platforms. Moreover, the educational sector should organise formal trainings in medical and nursing schools to introduce concepts of disability and ensure future health professionals have the confidence to provide effective care for people with disabilities. With countries ratifying the UNCRPD, and ongoing efforts to achieve universal health coverage, the next concrete step is political commitment to ensure all healthcare facilities and resources are inclusive and accessible. Multi-sectoral collaborations between ministries or departments, healthcare professionals, multi-lateral organisations, representative organisations, research, and education institutions, are essential in breaking down barriers to healthcare service access for people with disabilities.
Conclusion
Not having the skills and confidence to detect, interact with and treat disability can impose detrimental effects on people with disability. Negative healthcare professionals’ attitudes and stigma towards people with disabilities remain a major barrier in receiving equitable healthcare services. Currently, there is little evidence of a single effective intervention that could sensitise healthcare professionals on disability. However, there is promising evidence on interventions that include direct contact with people with disabilities, and when conducted regularly, may improve healthcare professionals’ ability in detecting disabilities and improve the quality of care.
Gaps & research needs
There is a need for long-term evaluations to measure the effectiveness of training interventions. Research in this area should collect data on patient’s satisfaction on care and serivces provided by healthcare professionals.
Furthermore, future research should aim to reveal the barriers and facilitators for improvement in healthcare workers’ skills, competency and confidence on disability.
Interventions needs to be both impactful and efficient if they are to be implemented in all settings. Limited evidence exists on the cost effectiveness of an intervention that aims to improve the knowledge of healthcare professionals on disability. Therefore, it is imperative that future research should also analyse the cost-effectiveness of disability training for healthcare professionals.
Acknowledgements
Peer Review: This brief has been peer reviewed by Tracey Smythe, Assistant Professor at the International Centre for Evidence in Disability, LSHTM.
Publication details: © London School of Hygiene & Tropical Medicine, January 2022.
Suggested citation: Fahrin Ramadan Andiwijaya. What works to improve healthcare professionals’ competency on disability? Disability Evidence Portal, 2022.