CHAPTER TWO

LITERATURE REVIEW

Introduction

This chapter reviews relevant literature on the topic. Literature was reviewed on the following

topics:

concepts of disability, models of disability, disability in Ghana, attitudes towards persons with

disabilities, culture and attitudes, disability identity and attitudes, barriers to healthcare by

persons with disabilities, attitude of student nurses towards persons with disabilities.

The Concept of Disability

Disability is a complex and dynamic concept influenced by historical, social, legal, and

philosophical factors, constantly evolving in its interpretation and understanding. While the lived

experience of disability remains unique to each individual, common themes and impacting

factors continue to emerge (World Health Organization, 2021).The concept of disability remains

a complex and contested terrain, constantly evolving within diverse academic and social

contexts. While the term "disability" itself is relatively new, its meaning and implications have

undergone significant shifts in recent decades

Prior to the 20th century, the term "disability" served primarily as a synonym for "inability" or a

descriptor for legal restrictions (Goodley, 2022). This understanding reflected the dominant

medical model, which viewed disability solely through the lens of individual impairments (Asan

& Farley, 2022).

However, the emergence of the social model of disability in the latter half of the 20th century

challenged this perspective. This model emphasizes the role of environmental and societal

barriers in creating disability, highlighting the crucial distinction between impairment and

disability (Charlton, 1998). Consequently, the term "disability" evolved into a social identity

encompassing a wide range of experiences and identities (Shakespeare & Watson, 2002).

While the evolution of "disability" as a term reflects valuable progress, it's critical to

acknowledge the limitations of singular definitions. Disability remains a multifaceted construct,

shaped by diverse factors like historical context, cultural understandings, and individual

experiences (Goodley, 2022). Instead of fixating on a single definition, focusing on

understanding the lived experiences of individuals with disabilities and fostering inclusive

practices proves far more meaningful (Barnes & Mercer, 2007).

The current definition by the World Health Organization (WHO) (2021) aligns with the social

model of disability. This model emphasizes the interaction between individuals with health

conditions and environmental and societal factors as the source of disability. In other words,

barriers, like inaccessible buildings or discriminatory attitudes, create disability, not just the

individual's impairment.

The International Classification of Functioning, Disability and Health (ICF):

The ICF (WHO, 2007) offers a framework for understanding disability, considering three key

aspects:

 Body functions and structures: Issues with bodily functions or structures, like mobility or

cognition.
  Activity limitations: Difficulties individuals face in performing daily activities, such as

walking or communicating.

 Participation restrictions: Problems individuals encounter in fully participating in their

communities due to environmental and social barriers.

Ghana's Persons with Disability Act (2006) adopts a similar viewpoint, defining a person with a

disability as someone experiencing functional limitations due to physical, mental, or sensory

impairments. These limitations, along with social and cultural barriers, can restrict someone's

participation in major life activities (p.17).

Definition of key words related to disability

Distinguishing between "impairment" and "disability" is crucial for comprehending the

experiences of individuals with disabilities and their implications. Since the 1970s, ongoing

discussions among international organizations like the WHO, disability scholars, individuals

with disabilities, and activists have shaped our understanding of these concepts.

The World Health Organization (WHO) (2021) has moved away from the International

Classification of Impairments, Disability and Handicap (ICIDH) (1980) definition, which

solely viewed impairment as a "loss or abnormality of... structure or function" (p. 47). This

medical model definition, where missing limbs or sensory organ loss automatically equates to

impairment, is now considered outdated and incomplete.

While the World Health Organization (WHO) (2001) definition of impairment as "problems in

the body functions or structure" provides a foundation for understanding disability, it's important

to acknowledge its limitations. The original WHO definition associates disability solely with
impairments in body functions or structures, potentially implying a direct link between

impairment and limitations in daily activities. However, this perspective overlooks the crucial

role of environmental and societal factors in shaping disability experiences.

The social model of disability, championed by organizations like the Union of the Physically

Impaired Against Segregation (UPIAS) (1976), challenges this individualistic view. It

emphasizes how disability arises from the interaction between individuals with impairments

and the built environment, social attitudes, and institutional practices that create barriers to

participation.

The text's focus on basic activities like walking, eating, and bathing, while important, can limit

our understanding of disability. Participation restrictions extend beyond daily tasks to

encompass social, economic, and cultural activities. An individual with an impairment might

face barriers to accessing education, employment, or leisure activities due to inaccessible

environments, discriminatory attitudes, or lack of support systems.

Instead of solely focusing on individual limitations, we should recognize how societal

structures and practices can create or exacerbate disability. This shift in perspective prompts us

to advocate for environmental and societal changes that remove barriers and enable full

participation for everyone.

Models of disability

The varying understandings of the relationship between impairment and limitation inform two

opposing approaches to disability, which is often described as the opposing models: the medical

and social models.

The medical model

The medical model of disability, while still prevalent in some contexts, has been extensively

critiqued for its limitations in understanding and addressing disability. This model views

disability primarily as a physical or mental impairment of the individual and its personal and

social outcomes (World Health Organization, 2021). It locates the restrictions faced by people

with disabilities (PWDs) as solely stemming from their impairments (Barnes & Mercer, 2003).

This understanding has several drawbacks:

 Focus on individual deficits: The medical model oversimplifies the complex interaction

between impairments, activity limitations, and participation restrictions (World Health

Organization, 2007). It prioritizes individual deficiencies, disregarding the significant

role of environmental and societal barriers in creating disability (Oliver, 1990).

 Medicalization of disability: The emphasis on medical etiology

risks pathologizing disability, leading to a view of PWDs as needing "fixing" rather than

empowered individuals navigating social structures (Charlton, 1998).

 Passive recipient of care: The "sick role" assigned to PWDs within this model can foster

dependence on medical interventions and limit their agency and participation (Wright,

1960).

Social Model

The social model of disability, emphasized by the WHO (2021), recognizes disability as arising

from the interaction between individuals with health conditions and environmental and societal
barriers. These barriers can be physical (inaccessible buildings) or attitudinal (discrimination).

The International Classification of Functioning, Disability and Health (ICF) (WHO, 2007)

further expands on this, encompassing:

 Body functions and structures: Impairments in functions like mobility or cognition.

 Activity limitations: Difficulties performing actions like walking or communicating.

 Participation restrictions: Challenges in fully engaging in the society due to

environmental and social barriers.

It's crucial to understand that disability is not a fixed state but rather a dynamic experience

shaped by various interacting factors. These factors can change over time, and interventions

addressing both individual needs and environmental barriers can significantly improve the lives

of people with disabilities.

Disability in Ghana

In Ghana, as with many African nations, cultural, social, and religious factors significantly

impact perceptions and attitudes towards disability (Gyamfi, 2022). Disabilities are often

attributed to curses or punishments for past transgressions committed by the person with a

disability (PWD), their family members, or ancestors (United Nations Development Programme

(UNDP), 2020).

Reincarnation Beliefs and Rejection:

Reincarnation beliefs are deeply ingrained in Ghanaian communities, leading some to perceive

disabilities as consequences of violating natural laws and deserving divine reprimand (Gyamfi,

2022). This can result in complete rejection of PWDs in certain cultures, perceiving them as
outcasts or sources of misfortune (Asiedu et al., 2018). Additionally, the stigma attached to

disability might lead families to resentfully care for PWDs due to perceived financial burdens

(Amoatey, 2019).

Supernatural Attributions and Barriers:

Ghanaian culture also associates disabilities with witchcraft, sorcery, "juju", and magic (Asiedu

et al., 2018). These superstitious beliefs fuel mixed feelings towards PWDs within traditional

communities, creating significant obstacles to social inclusion (Kuyini, 2014). Such entrenched

belief systems can hinder positive interactions and understanding between PWDs and non-

disabled individuals (Naami & Hayashi, 2012).

While Ghana generally upholds the ideals of inclusion and equal rights for Persons with

Disabilities (PWDs), significant variations in perceptions exist across its diverse cultural settings.

These perceptions range from tolerance and incidental integration to reverence and full

participation, often rooted in traditional beliefs and practices.

Among the Ashanti of central Ghana, traditional beliefs did historically restrict individuals with

physical disabilities from certain roles, including chieftaincy (Addae-Mensah, 2017). The

practice of de-stooling a chief upon acquiring disabilities, like epilepsy, also reflects these past

norms (Sarpong, 1974). Similarly, rejecting children with perceived abnormalities, such as

killing infants with polydactyly (Rattray, 1952), and abandoning "river babies" with severe

intellectual disabilities (Danquah, 1977), were documented in some historical accounts.

However, it's crucial to recognize that these practices may not represent the full spectrum of

historical and contemporary attitudes within the Ashanti community.

In contrast, the Ga people from Greater Accra region historically held individuals with cognitive

impairments in high regard, attributing their condition to divine reincarnations (Field, 1937).

This resulted in treatment marked by kindness, gentleness, and patience. Recognizing such

diverse perspectives challenges simplistic narratives of widespread discrimination against PWDs

in Ghanaian cultures.

Understanding the historical context and variations in perceptions is crucial to address current

challenges and promote inclusive practices for all individuals, regardless of disability. Focusing

on individual experiences and fostering dialogue across communities can help dismantle

discriminatory practices and build more equitable societies.

Attitudes towards Persons with Disability

Attitudes, deeply embedded within our social fabric, significantly influence how we

perceive and interact with the world around us, including individuals with disabilities.

Understanding their complex nature is crucial for fostering inclusive and equitable

societies.

While various disciplines have tackled the definition of "attitude," Gordon Allport's (1935)

seminal work remains influential. He described it as "a mental and neural state of readiness,

organized through experience, exerting a directive or dynamic influence upon the individual's

response to all objects and situations with which it is related" (p. 810). Fazio (2009) reinforces

this notion, highlighting the enduring impact of experience on shaping our predispositions.

Eagly and Chaiken's (1993) definition, characterizing attitude as "a psychological tendency,

expressed by evaluating a particular entity (person) with some degree of favor or disfavor" (p. 1),
captures the essential evaluative aspect. However, contemporary models acknowledge the

complexity of attitudes, encompassing not just favorability but also cognitive beliefs and

behavioral tendencies (Ajzen & Fishbein, 2005). This understanding emphasizes how attitudes

go beyond mere liking or disliking and influence how we process information, make judgments,

and interact with others.

Coleridge's (1993) assertion that "it is attitudes that disable" highlights the profound impact

attitudes have on the lived experiences of people with disabilities. Negative attitudes, such as

disgust, fear, or prejudice, can create significant barriers and contribute to social exclusion and

discrimination. This, in turn, can reinforce feelings of isolation and marginalization, perpetuating

a cycle of disadvantage.

The good news is that attitudes are not static but rather malleable and susceptible to change

through education, personal experiences, and intergroup contact (Pettigrew & Tropp, 2008). By

fostering empathy, understanding, and challenging negative stereotypes, we can create a more

inclusive and equitable society for everyone.

Prejudice and stigma surrounding disability can lead to significant barriers in accessing essential

services and opportunities. These barriers disproportionately impact individuals with disabilities

(PWDs), hindering their participation in health, education, and employment, and often pushing

them into poverty.

A 2021 report by the World Health Organization (WHO) highlights that 1 billion people globally

experience disability, with those in developing countries facing the most significant challenges in

accessing healthcare. Negative attitudes and discriminatory practices often prevent PWDs from
receiving proper medical care and rehabilitation services (WHO, 2021). This lack of access can

further exacerbate existing health conditions and limit opportunities for self-reliance and quality

healthcare.

Negative community attitudes towards PWDs are particularly prevalent in developing regions,

according to a 2018 UN report (UN, 2018). These attitudes often lead to low expectations of

PWDs, hindering their ability to reach their full potential and participate actively in society. Such

limitations can restrict educational and employment opportunities, further perpetuating poverty

and social exclusion.

Combating negative perceptions and promoting inclusive attitudes are crucial to dismantling the

barriers faced by PWDs. This requires comprehensive strategies that address both individual and

societal levels. Educational initiatives can challenge discriminatory beliefs and promote

understanding of disability, while policy changes and infrastructure improvements can ensure

equal access to essential services and opportunities. By fostering a more inclusive and equitable

society, we can empower PWDs to reach their full potential and contribute meaningfully to their

communities.

Culture and attitudes

Cultural orientation undoubtedly influences attitudes towards disabilities, presenting a crucial

factor for examination. However, the relationship is nuanced and not always straightforward.

While Goffman's (1963) work highlighted the role of social norms and influences in shaping

stigmatizing attitudes, recent research emphasizes the dynamic interplay between cultural values

and individual experiences (Zhang & Zhao, 2022). Cultures can foster stigma by associating
disability with negative stereotypes or limiting opportunities, but they can also promote inclusion

and acceptance (Yasuda, 2023).

Cultural norms do play a role, as Yang et al. (2007) suggested, but it's crucial to consider the

context. Coker (2005) found that in Egypt, negative attitudes towards intellectual disabilities

correlated with endorsing specific cultural norms. However, simply adhering to specific norms

may not translate directly to negative attitudes across all cultures.

Rao et al. (2010) proposed that cultural characteristics might explain variations in stigma across

cultures. Their study examining employers' attitudes towards disabled employees found that

individualistic cultural orientations did indeed correlate with more negative stigma, aligning with

their hypothesis. However, they also discovered that perceptions of disability cause played a

more significant role than cultural orientation alone.

Understanding the relationship between cultural orientation and disability attitudes requires

acknowledging the complex interplay of cultural norms, individual experiences, and contextual

factors. While cultural characteristics may contribute, individual perceptions and societal

structures often play a more significant role in shaping attitudes and fostering inclusion.

Disability identity and attitudes

Greater emphasis on attitudes towards PWDs has been placed on people without disabilities.

However, it is also of importance to consider how PWDs view others with the same disability,

with different disabilities, and the disability group as a whole population. Possible factors that

could influence these attitudes include whether an individual views his or her disability in a
positive or negative way and the extent to which the disability has been integrated into one’s

own identity.

Identity, defined as the way we understand and perceive ourselves, is shaped by both internal and

external forces (Smith & Vogt, 2022). For individuals with disabilities (PWDs), navigating this

personal journey involves confronting not only their own perception but also societal views and

biases.

Living with a disability can significantly influence both self-perception and the way others

perceive the individual (Owens & Joffe, 2023). This necessitates integrating the reality of one's

disability into their overall identity, forming a crucial step in adapting to its impact on daily life

(Albrecht & Berendt, 2020).

Adaptation to disability often requires emotional, cognitive, and behavioral adjustments aimed at

achieving harmony with one's environment (Wendell, 2019). However, simply having a

disability doesn't guarantee the development of an identity that fully embraces it (Dunn &

Burcaw, 2013).

Hahn and Belt (2004) proposed a dualistic view of disability identity (D.I.), consisting of

personal and communal dimensions. The personal aspect involves recognizing oneself as a

PWD, while the communal aspect fosters a sense of connection to the broader disability

community (Hahn & Belt, 2004). Fostering a positive connection to this community can further

cultivate a more affirmative attitude towards other PWDs in general.

The concept of disability identity (DI), encompassing the sense of belonging to a community of

individuals with disabilities, is a relatively recent area of research gaining significant traction.
Studies suggest that a positive DI, characterized by self-acceptance and identification with the

disability community, can lead to enhanced life fulfillment and self-confidence (Wilton &

Gilpin, 2019; Hehir et al., 2023). This may further positively impact social interactions and

relationships due to its association with increased life satisfaction. However, the specific

influence of DI on attitudes towards disabilities in general remains understudied.

Coleridge's (1993) assertion regarding the subjective nature of human behavior and attitudes

holds true in the context of disability. As highlighted by Linton (2019), disability justice

movements emphasize the need for PWDs to challenge societal perceptions and advocate

for their rights. This self-advocacy, coupled with positive self-regard and a belief in one's own

capabilities, can contribute to a gradual shift in societal attitudes. Essentially, PWDs refusing

the victim role and actively shaping their narratives can pave the way for more inclusive and

empowering societal perceptions.

Barriers to healthcare by persons with disability

People with disabilities are at risk for many health-related problems because they are vulnerable

to deficiencies in health care services. In addition, and more importantly, the concerns of persons

with disabilities are not addressed adequately in many healthcare programs and policies because

of cultural, attitudinal, and institutional barriers (WHO, 2000).

Persons with disabilities have greater health needs and concerns than persons without disabilities

but many health care providers are ignorant of their needs. According to Aulangnier, (2005)

primary care consultations can take lengthier for PWDs than for people without disabilities. It

was also noted that, adults with intellectual impairment often require extra time for check-ups,

screening, clinical procedures, and health promotion.

However, health care providers are often not compensated for the extra consultation time they

spend with PWDs and the disparities between actual cost and reimbursement can be a

discouragement for service providers to provide comprehensive health care. Short consultations

may leave little time for HPs to appreciate and address the sometimes-multifaceted health care

needs of people with disabilities.

Persons with disabilities (PWDs) frequently report dissatisfaction with healthcare providers,

particularly nurses, citing issues related to both individual attitudes and systemic training gaps

(Haak et al., 2023; Al-Amin et al., 2022). This dissatisfaction can stem from pre-conceived

notions held by healthcare professionals prior to their interactions with PWDs (Hu et al., 2021).

Attitude of student nurses towards persons with disabilities

Student nurses' attitudes towards PWDs can significantly impact their interactions and

potentially contribute to healthcare disparities (Moser et al., 2022). This is because healthcare

professionals often mirror societal norms and biases towards PWDs (Mendes et al., 2023).

Studies suggest that negative attitudes among student nurses can contribute to unequal access to

healthcare for PWDs (Balogh et al., 2020).

For example, a recent study by Al-Asmari et al. (2023) found that nursing students in Saudi

Arabia exhibited negative attitudes towards PWDs, highlighting the need for targeted

interventions to address these biases. Similarly, in a systematic review by Olagunju et al. (2023),

negative perceptions towards PWDs were identified among healthcare students across various

countries, including Bhutan, where Dorji and Solomon (2009) also reported less positive

attitudes among student nurses.

These concerns emphasize the importance of understanding student nurses' attitudes towards

PWDs to foster culturally competent and inclusive healthcare practices. While cultural and

traditional interpretations of disability can often lead to negative perceptions (Swindells et al.,

2020), targeted training during pre-professional education can significantly improve attitudes and

support positive interactions with PWDs (Olagunju et al., 2023).