Assistive technology and daily living challenges among students with disabilities at University of Gondar, Ethiopia: a qualitative study

Abstract

Background

Disability influences activities of daily living, leading to unsafe conditions, poor quality of life, and dependence on others and assistive technologies. Despite limited access and unmet needs, assistive technology enables users to participate in education and be independent members of their community. Students with disabilities in higher education face many challenges in their day-to-day activities and evidence is limited in the study area. Therefore, this study aimed to explore assistive technology experience and daily living challenges among students with disabilities in higher education.

Method

A descriptive qualitative study design was employed at the University of Gondar, Gondar, Ethiopia, between December 20, 2022, and January 20, 2023. A purposive sampling method was employed to recruit 14 students with disabilities. An in-depth interview was employed using semi-structured questionnaires. Open Code version 4 software for coding and reflexive thematic analysis approach was employed for the analysis.

Result

A total of 14 students with disabilities were included in an in-depth interview. Four main themes emerged, which included activities of daily living, attitudes toward people with disabilities, barriers to accessibility, and access to assistive technology.

Conclusion

Barriers to activities of daily living among students with disabilities were poor accessibility of infrastructural facilities, lack of teaching/learning materials in an accessible format, and negative attitudes. The present study’s finding is needed to support students in higher education for their academic achievement and to design appropriate rehabilitation strategies and policies on the accessibility of physical infrastructures, inclusive education, and the provision of assistive technology

Keywords:

• Assistive technology
• disability
• students with disabilities
• daily living challenges

Introduction

Disability is the result of the interaction between individuals with physical health conditions and personal, social, or environmental factors, such as negative attitudes, lack of accessible transportation, public buildings, and limited social support [1]. It is estimated by the World Health Organization (WHO) that 16% of the global population currently experiences a disability and that almost everyone will experience disability at some point in their lives [2]. The WHO International Classification of Functioning, Disability, and Health (ICF) biopsychosocial model considers disability in Activities of Daily Living (ADL) as a multifactorial concept [3]. Activities of daily living (ADL) refer to fundamental skills required to care for oneself independently and indicate a person’s functional status. For people with disabilities, ADLs are influenced by health conditions, body functions and structures, environmental and personal factors, and participation. The inability to complete essential daily tasks can lead to unsafe conditions, reduced quality of life, and dependence on others and machinery [4,5].

Students with disabilities encompass a diverse population, including those with physical, sensory, cognitive, and communication impairments [6,7]. Physical disability is defined as a limitation on a person’s physical functioning, mobility, dexterity, or stamina that has a substantial and long-term negative effect on an individual’s ability to do normal daily activities [8]. On an individual level, impairments limit the extent to which people with physical disabilities are involved in some activities, and they spend more time on the activities of daily living than the average population. Individuals with physical disabilities find their social interactions and social networks limited with social isolation affecting the range of their life experiences and influencing their effectiveness in social situations [9–11]. In addition, because of their impairment people with disabilities sometimes feel like they are less valuable as human beings [12–14]. Despite limited social interaction, studies indicate that students with disabilities interact with each other to a greater degree than with classmates without disabilities [2]. Literature shows that students with disabilities in higher education face both physical and attitudinal barriers [15]. The barriers include non-working elevators, computers in the library without screen readers, outdated screen readers that are not compatible with books, uneven hallways that cause discomfort for wheelchair users, toilets that can’t be used by wheelchair users, the university cafeteria not being accessible for students with disabilities, and stigma and discrimination against students with disabilities [16]. They often encounter numerous challenges in their daily lives, many of which can be addressed or mitigated through the use of appropriate assistive technology [17–19].

Assistive technology (AT) plays a crucial role in addressing the daily living challenges faced by students with disabilities [20]. AT is an umbrella term for assistive products such as wheelchairs, glasses, prosthetic limbs, white canes, and hearing aids to a wide range of devices, software, and equipment specifically designed to enhance the functional capabilities and independence of individuals with disabilities [21]. One billion people need assistive products today and more than two billion people worldwide will need at least one assistive product by 2030. These technologies are designed to bridge the gap between an individual’s abilities and the demands of their environment, including educational settings. In the context of students with disabilities, AT serves as a valuable tool for promoting equal access to education and supporting their overall well-being [22,23].

Assistive products support students of any age in enjoying their right to education and being successful and included at school, in vocational training, and higher education [24]. When assistive products are used in accessible school environments (e.g., settings with ramps to allow wheelchair access) and are welcomed and included by teachers and other students, students with disabilities are less likely to be marginalized, achieve better educational outcomes, and have more opportunities for social interaction [25–27]. For instance, a study done in Morocco and Egypt showed students with vision problems use assistive technology to improve education which include mobile phones to record lectures, tablets to take photos of the whiteboard, GPS for navigation, audio files to modify words, braille machines for typing, and audio devices for use after lectures at home [28]. Access to appropriate assistive technology can also support students’ educational engagement, increase well-being and academic self-efficacy, and positively impact competence, adaptability, and self-esteem [29]. According to Kisanga and Kisanga, assistive technology plays a significant role in helping visually impaired students in higher education become more self-confident and independent. It also enhances students’ interactions among themselves regardless of their disabilities, peers, and the learning material, as well as their access to electronic resources for accessing and storing information from the internet and libraries around the world [30]. Findings from a systematic review of the impact of AT for SWD in higher education indicated that AT use can support the ability to perform academic tasks, engagement with educational materials, and academic performance [31]. The barriers to accessing assistive technology may include but are not limited to funding for assistive technology, training, a lack of appropriate teacher preparation and support, negative staff attitudes, insufficient assessment, insufficient financial support, difficulty obtaining and managing equipment, and time constraints and insufficient assessment and planning processes for AT design and development [32].

Evidence shows assistive technology providers neglect the psychosocial and functional perspectives of people with disabilities during the design and development of assistive technologies [33]. It is essential to involve individuals with physical disabilities in a co-design process that encompasses verbal information and hands-on experience with devices to enable them to make informed decisions regarding design and development. Integrating devices into educational practice is crucial, and students should see immediate benefits in their daily school activities without negative impacts on their social participation [33–35]. Despite assistive products having many benefits, access, and needs of users remain limited. A better understanding of daily living challenges and the met and unmet needs of assistive technology users can assist in anticipating the accessibility and human support needs of individuals with disabilities, and in turn, inform resource allocation and prioritization of services. Therefore, this study aimed to explore activities of daily living challenges, barriers to access, met and unmet needs of assistive technology users, and perspectives on the design and development of assistive technologies among students with disabilities in higher education.

Methods

Study design and setting

A descriptive qualitative study design was employed to explore the challenges faced by students with disabilities in the activities of daily living and evaluate their perspectives on the design and development of assistive technologies. This study was conducted at the University of Gondar, Ethiopia, between December 20, 2022 and January 20, 2023. Currently, the University of Gondar has five Campuses, namely, the College of Medicine and Health Sciences, Maraki, Aste Tewodros, Atse Fasil, and Teda campus. The University of Gondar provides 87 undergraduate, 137 master’s, and 29 doctoral programs for over 45,000 students. More than 400 students with disabilities are studying at the University, with most of them enrolled in undergraduate programs in the social science departments.

Study population

Participants included students with sensory or physical disabilities studying at the University of Gondar. Inclusion criteria included adult men and women students (18+) who (a) had been studying at the University of Gondar; (b) could speak the national language Amharic, and (c) volunteered to participate.

Sampling method and participant recruitment

Fourteen students with disabilities (physical disability and visual impairment) were recruited through representatives of students with disabilities in the university and department heads. They were asked to identify potential participants and forward to them information about the study. The potential participants were then contacted directly by the researchers. Information about the study was also forwarded by the researchers to people who had participated and indicated their willingness to take part in the study. A purposive sampling technique based on the diversity of participants in age, gender, type of disability, and residence before joining the university (urban/rural), department, and year of study. Considering the study’s purpose, the concept of information power was used to determine the point at which the data collection ended [36].

Data collection

We obtained ethical clearance from the University of Gondar’s Institutional Ethical Board. One of the authors, AKK, who had no academic interaction with the students identified and approached participants to explain the purpose of the study and obtain informed consent. He then interviewed the students in a private room at the University using Amharic (the local language) and a semi-structured guide with probes. The questionnaires were developed by the authors from different sources to suit respondent’s needs, context, and topic and validated by inviting experts from the field to read through the questions and give their feedback. In English, some of the semi-structured questions were:

A) What are the daily activities you find most challenging?

B) Why do you find these activities challenging?

C) Have you ever used assistive technology?

D) What kind of assistive technologies have you used or are now using and what is the role?

E) How satisfied are you with the current AT and do you feel that you received the AT that you need?

F) What was your role in the design, development, and maintenance of any assistive technologies you have been using?

G) How satisfied are you with the development, repair, maintenance, and follow-up services based on your experience?

The interview was audio recorded and transcribed verbatim in Amharic and then translated into English for analysis. The interviews lasted 40-60 min. The interviewer wrote field notes immediately after each interview to capture the overall interview context and meaningful gestures not expressed verbally.

Trustworthiness

AKK scheduled appointments with the students, arranged interview locations, creating a good relationship to conduct engagement in the main interview. AKK regularly monitored and recorded his interaction with the participants and how he reacted to the participants’ views regarding their perspectives about the challenges of daily living and perspectives towards assistive technologies to minimize preconceptions that could negatively affect the study’s procedure and findings. In addition, the quality was maintained by using detailed descriptions and use of quotes during reporting findings.

Data analysis

We applied reflexive thematic analysis using an inductive approach. Reflexive thematic analysis is a conceptually flexible and generally accessible interpretative approach for analyzing qualitative data that makes it easier to find and analyze patterns or themes within a given set of data [37].

First, the interviews were transcribed verbatim into Amharic and then translated into English by two experts both in Amharic and English to minimize meaning loss. The English transcript notes were imported into Open Code version 4 software. Then we followed six phases of Braun and Clarke’s thematic analysis approach [38] which include

1. Familiarizing ourselves with the data: Immersing oneself in the data to understand the depth and breadth of the content and searching for patterns and meaning begins,

2. Generating initial codes: Generating initial codes to organize the data, with full and equal attention given to each data item,

3. Constructing themes: Sorting of codes into initial themes, identifying the meaning of and relationships between initial codes,

4. Reviewing potential themes: Identifying coherent patterns at the level of the coded data and reviewing the entire data set as a whole,

5. Defining and naming theme: Identifying the story of each of the identified themes and fitting the broader story of the data set to respond to the research questions and

6. Producing the report: Presenting a concise and interesting account of the story told by the data, both within and across themes

The analysis started with familiarization of the data by listening to the audio records, reading and re-reading transcribed data, and by note-taking to understand the depth of the data content by AKK who collected the data. This phase is followed by generating initial codes by labeling and organizing data items into meaningful groups, with full and equal attention given to each data item.

In phase three, AAK sorts all codes that share similar meaning or have a relationship to generate initial themes. This phase is followed by identifying coherent patterns at the level of the coded data and reviewing the entire data set as a whole to ensure as there is enough data to support a theme, collapsing overlapping themes and re-working and refining codes and themes. Two authors compared initial codes to confirm their appropriateness in echoing participants’ voices and addressing the research question.

In the fifth phase, each of the identified themes was defined to fit the broader story of the data set to the research questions. The different levels of themes were also discussed with other authors throughout the analysis process and adjusted or modified as relevant based on discussions. As a final step, we reviewed and revisited the final themes and the meaning of each theme. Finally, all co-authors reviewed, edited, and offered their suggestions to enhance the quality of the report.

Ethical considerations

The ethical approval was obtained from the University of Gondar’s ethical review board. We received written informed consent prior to each interview from each participant. AKK read the consent document to participants who couldn’t read or write, and they thumb-printed it as their consent. We removed all names and other identifiers from transcripts and records to ensure anonymity, presented the findings in a de-identified format, and only the investigator’s team gained access to the data.

Result

A total of 14 students with disabilities were included in in-depth interviews. Almost all participants were originally raised in a rural area before they joined the university. Of the participants eight (8) of them were females. The types of disability included participants who had arm, hand, mobility, and/or visual impairments. Except for a single participant identified with an idiopathic congenital etiology of loss of vision, the cause of impairments for all participants had acquired their disability between 3 and 12 years old due to maltreatment by traditional healers and rather than early attendance at a medical center such as a hospital. Table 1 shows the socio-demographic characteristics of study participants

Table 1. Socio-demographic characteristics of study participants.

Participant Number(P#)	Sex	Age(yrs.)	Field and Year of Study	Type of disability	AT participants use
1	F	24	1st Year MSc Law	Loss of vision	White cane, audio recorder, and Jaws software
2	F	24	5th Year BSc Law	Loss of vision	White cane, audio recorder, and Jaws software
3	F	21	1st Year BSc Freshman courses	Loss vision	White cane, audio recorder, Jaws software, and Brail
4	M	23	2nd Year BSc Law	Amputated fingers and mid-metatarsal	Prosthesis
5	F	27	2nd Year MSc Gender	Loss of vision	White cane, audio recorder, and Jaws software
6	M	24	5th Year BSc Law	Partial loss of vision	White cane, audio recorder, Jaws software, Brail, and ANBDA
7	F	29	5th Year BSc Law	Polio “trunks and both lower limbs involved”	Wheelchair
8	M	26	3rd Year BSc Accounting	Polio” left upper limb, trunk, and both lower limbs involved”	Wheelchair
9	M	22	1st Year BSc Freshman Courses	Below-knee amputation and just foot deformity of the other leg	Prosthesis and Ankle Foot Orthosis (AFO)
10	M	22	1st Year BSc Freshman Courses	Above knee amputation	Wheelchair, crutch, and prosthesis
11	F	22	1st Year BSc Freshman courses	Above elbow amputation	No use of AT
12	F	24	2nd Year BSc Social work	Above elbow amputation	No use of AT
13	M	22	5th Year BSc Law	Polio both lower limbs involved	Prosthesis and crutch
14	F	23	3rd Year BSc Sociology	Above elbow amputation	Prosthesis

F: Female; M: Male; BSc: Bachelor of Science degree; MSc: Master of Sciences.

Challenges of daily living and perspective towards assistive technologies

Four main themes emerged from an inductive reflexive thematic analysis. The themes included; “Activities of daily living”, “Attitudes toward people with disabilities”, “Barriers to accessibility”, and “Access to assistive technology”.

Theme one: activities of daily living

There are three areas within the realm of activities of daily living that affect university students with disability. These include self-care tasks, educational needs, and functional limitations as a result of the environment.

All participants stated that they are capable of undertaking self-care tasks such as eating, bathing, dressing, using the restroom, doing their hair or makeup, brushing their teeth, and moving around. Depending on the severity and type of impairment, each person has different functional limitations. For instance, a student who has lost their vision may be able to undertake activities of self-care such as hair-styling and washing their body, but they may be unsure about thorough cleaning to ensure that soap is completely removed. They sometimes seek additional assistance from their friends to help check the cleanliness of their clothes. A participant said:

…I do all tasks though I have limitations to performing some activities like people without disabilities. For instance, I always hesitate about whether I clean it or not when I wash my body, clothes, and floor. I can wear clothes by myself but have challenges selecting colors and making sure it’s clean… [P3]

Persons who have upper limb impairment also have limitations in performing some self-care activities. Lack of physical function leads to issues with washing their body and clothes, styling their hair, and eating foods that need both hands to function. Clothes and shoes that also require two hands such as buttoning or lacing limit access to clothes and shoes they might prefer.

Engaging effectively within a classroom environment is impacted for persons with disability. Participants with loss of vision mentioned their challenge in taking notes during lectures and reported frustrations with barriers during assessments. During examinations, students with vision impairments are provided assistance in the form of a support person for reading and writing. However, the support person is not trained in the subject area of the assessment which creates challenges like pronunciation issues during reading, misunderstanding between the support person and the student, issues with writing, and limited time to complete the assessment. The accommodations provided do not account for the additional needs of the student resulting from the need to interact with someone unknown to the student. For persons with upper limb impairments, schooling is affected such as writing and taking notes in the class, as the paper slides or lacks support from the other hand. There are also difficulties in turning pages of academic books, fictional works, and religious books. Many believed that their academic performance was reduced due to the impact of their impairment in writing especially during exams.

A participant stated: “…I tried to take notes during lecturing but I can write slowly and many relevant points might be missed when I write. … It was difficult for me to complete the exam as I wrote slowly and I submitted the exam with some questions left unanswered. As a result, I thought I didn’t perform as I could due to my impairment at my hand. Now I started to use exam supporter…” [P14].

Functional limitations for activities of daily living can include basic hygiene requirements such as bathing/showering and access to water. In this example, the student discusses access issues that prevent him from effective participation. Other participants explained that they face some issues but they try to draw on friends living with them to help or try to ask people without disabilities for extra help. A participant with lower limb impairment of both limbs (left transtibial and right equines deformity) stated:

I wake up first, wash my face, eat my breakfast, go to class and library to study, have coffee, and enjoy myself with my friends. What I can’t do is run. Furthermore, there is limited access to water on campus. So, we are subjected to fetching water from somewhere else. In addition, the toilet and shower rooms are slippery which makes me very challenging. [P9]

Theme II: attitude towards people with disabilities

All participants indicated the presence of both positive and negative attitudes experienced in the past and present toward people with disabilities. Participants stated that attitudes towards people with disabilities have changed a lot and people living in urban areas have better awareness and generally more positive attitudes toward people with disabilities than those living in rural areas. Many people who have a positive attitude believe people with disabilities can perform like others, and favor in many places of service. They respect and socialize with people with disabilities without any discrimination or stigma.

While some people support PWDs, negative attitudes, stigma, and discrimination toward people with disabilities hinder the quality of life, social participation, and productivity. PWDs are judged to be not as competent as people without disabilities. These negative attitudes are experienced within families as well as greater society.

Almost all participants explained that their family first thought the cause of the disability was due to evil acts or sin. The primary preference for the early management of diseases such as these includes a traditional healer and Holy Water. Treatment at a hospital will only occur when the condition worsens and the family realizes that the first choice of action is inadequate. A participant reported that the cause of her disability was as follows:

I lost my vision at the age of five years old. “My family believed that it was because of a family sin … During that time, traditional tropical medicine was applied to my eye instead of taking me to the hospital”. [P3]

Once a person has acquired a disability, family members deem the individual less competent, which results in many parents preferring that their children join religious schools instead of modern education. Other members of society group all people with disabilities who have similar functional limitations together, believing that PWDs are dependent on specific activities. They believe that PWDs have limited financial capacity as many are seen begging in the street or working as shoeshines. A participant with a mobility disability explained how negative attitudes limit his social participation:

…awfully what I frequently encountered is people staring at me and sucking their lips when I meet them in many places. In addition, although we were graciously invited, many people see me as a beggar. For instance, one day a person at a celebration came and tried to give me 50 cents and told me to leave the party. [P4]

Another participant with a loss of vision described how they were treated when members of society did not understand disability (and how it is acquired):

…society still discriminates and stigmatizes us in many ways. The child of the people who owned the house I rented out came to hug me one day, but her mother called her daughter and took her away immediately because she was upset. I told her my impairment can’t transmit from person to person because I was shocked and felt horrible by her action. [P5]

Barriers to effective integration result from a lack of society’s understanding of both intellectual ability and disability itself. Constructing facilities and developing services that are specific to PWDs results in positive discrimination but also leads to emotions of dissatisfaction and loneliness among students with impairments. Participants suggested educating the community as a key factor in promoting positive attitudes and awareness toward people with disabilities. A participant with mobility impairment stated that:

…generally, many people including students in higher education think PWDs can’t perform ADLs, can’t academically perform like people without disabilities when they first meet us. As a result, students in the university don’t want us to be their close friends. [P7]

Theme III: barriers to accessibility

Students with disabilities encountered physical barriers to educational services, such as a lack of ramps and/or elevators in multi-level class buildings, heavy doors, inaccessible washrooms, libraries, restrooms, cafeterias, hospitals, offices, and/or inaccessible transportation to and from lecture rooms. Students also experienced physical barriers outside of the university that challenge their ADL which includes access to buildings, public spaces, banks, religious places, markets, and roads. Participants suggested that services and facilities are not built to consider the needs of people with disabilities and to enable their use by people of all abilities. Many important offices, classes, libraries, cafeterias, and hospitals in the university are not accessible to PWDs. Most of the places have poles on the main roads, obstacles, and no ramps with only stairs. Regarding access to the classroom, a participant explained this issue as follows:

Accessing classrooms is challenging for me since it found going upstairs and no ramps in most of the places. I fear going upstairs above the first floor and I always think what if they push me and fall when I go upstairs. [P2]

Another participant explained: “Access to the toilet room is challenging where the door opens to the outside which is difficult to turn and close as it is narrow and not suitable for wheelchair users. So, I put my wheelchair outside and slide with my hand and leg …. Café lounges are also not accessible there are many stairs and no ramps. So, they serve me outside of the restaurant.” [P8]

This participant also explained the inaccessibility of the environment “… I didn’t deposit or withdraw money by myself from the bank… In addition, all markets are not accessible to wheelchair users like me to shop for clothes, shoes, and other basic needs. What I do is that I stay far from a shop and call them to show me clothes or shoes…. So, I usually buy it if the size fits me even though I am not interested.” [P8]

Physical barriers make access to the educational environment very challenging. A participant with a mobility impairment explains the physical barrier in the following way:

The mountainous Gondar landscape is not suitable for those who have physical impairment like me. I can’t move in the campus as I want since the area is mountainous and it is also difficult to get back to my living room after I went out of the campus. [P10]

Theme IV: access to assistive technology

Almost all participants have access to at least one assistive technology. As expected, different technologies are required for different populations. Persons with visual impairment have access to many types of AT while those with mobility impairment are more limited. The assistive technologies used by students with vision impairment include a white cane, Jaws software, ANBDA, and an audio recorder. Visually impaired students use a white cane to navigate and scan obstacles and steps in the environment. The white cane can also be used across partially vision-impaired individuals for protection, warning the people around them. A participant with loss of vision explained her use of assistive technologies as follows:

I am using a white cane, sound recorder, ANBDA, and jaws but I used to brail before I joined university. I use a white cane to navigate and scan the environment and others to read soft copies from the computer and mobile written in many languages which includes religious books, fiction, and other academic reading materials written. [P6]

All participants with loss of vision described the use of Jaws and ANBDA with their cell phone or computer to read soft copy academic reading materials, religious books, and fiction in the language they need. Since they are unable to take brief notes during lectures, they also record the lectures using an audio recorder. They repeatedly listen to the recordings to get ready for exams. A participant explains the role of AT as follows:

… I started to use audio recorders, and Jaws started using a soft copy for the first time from scratch at university. But it was very challenging to use it and I can’t access hard copy reading materials. As a result, I believe I scored lower academically. [P6]

Additionally, students with impairments proved that hardcopy reading materials are inaccessible and that they solely use softcopy instructional materials. According to students with disabilities, the lack of braille in higher education has an impact on their academic performance, particularly during their first year of study when they are still getting used to the various software programs available for reading academic texts. Participants who had mobility impairment used wheelchairs, prostheses, orthotics, and crutches. Those with lower limb and trunk impairment use assistive devices to move from place to place as long as the places are accessible. They indicate that assistive devices help them to attain and maintain maximum independence, through full physical, mental, social, inclusion, and participation in all aspects of life. However, almost all participants indicated that assistive devices are not available close to where they live, and they need to travel significant distances to gain access. A participant explained his AT experience as follows:

I used a wheelchair and crutch in the early rehabilitation phase of post-surgical amputation till I received my prosthesis from the Bahir Dar rehabilitation center. Now I strongly believe that I am not inferior to others (people without disabilities) and I achieve this with my device. [P10]

Though many students with vision and lower limb impairment had access to AT, those with upper limb impairment had no access to any device that met end-user needs.

Despite my desire to obtain an assistive device, I was unable to obtain one at the rehabilitation center that best fits my interest. So, I didn’t use any assistive device yet mainly due to short trans-humeral amputation which makes the design and development difficult. [P12]

Unmet needs and role of users in assistive device development

Though many students with disabilities have access to assistive technology, the device doesn’t necessarily meet the user’s needs. However, many participants are happy with the assistive device that they are provided given the limitations that exist. Almost all participants need other additional assistive devices that can better support their day-to-day activities. A participant expressed her unmet needs as follows:

…though my devices are comfortable and suitable, there are many devices I need to get like a white cane with a sensor, devices that can read a hard copy, smart audio recorder, and a smartphone. However, I can’t access it since most of these things are expensive. [P1]

Another participant also expressed:

…I used a prosthesis before 6 years ago. But it was heavy, looked large and cosmetically not good, felt hot, and rigid, and had no relevance in any of my ADL activities. So, I discontinued using it since I was not satisfied with it. [P11]

Many providers have no interest in including users in the decision-making process of assistive device design and production. They rely on generalized parametric measurements instead of co-designing with the final users of the devices. Students with disabilities showed that the development and maintenance process of assistive technology is not easy and interesting. Rehabilitation centers do not have enough access to the materials and expertise needed mainly due to the transfer of responsibility from non-government organizations (NGOs) to the government. The government does not value the needs and contributions of persons with disabilities providing little attention and financial support in this area. The rehabilitation centers recognize that their resources for producing new devices and materials for maintenance are limited. A participant stated the experience of AT design, development, and maintenance as follows:

I have no role in the design of my prosthesis. I think they have a fixed design so they took a measurement, made it, fit it, and gave it to me. But nowadays it is very worrying since the Bahir Dar rehabilitation center workers usually say we have no material. Think about what will be our chance if they stopped it, all our activities will also automatically stop. [P13]

Discussion

This study explored the experiences of 14 university students with disabilities. Findings identified critical barriers that students with disabilities encounter in activities of daily living, access to assistive technology, and insights into the design and development of assistive technology. The themes found in this study reinforced previous findings concerning activities of daily living, attitudes toward people with disabilities, barriers to accessibility, and access to assistive technology.

The first identified barrier was performing activities of daily living including self-care, productivity, and social participation. The challenges faced by students with disabilities vary based on the type of disability or impairment. Challenging activities include washing, selecting clothes, eating foods (especially in restaurants), shopping within inaccessible environments, performing academically when provided with minimal accommodations, and an inability to participate in religious ceremonies, weddings, and birthday celebrations. Additionally, negative perceptions by professors lead to a lack of academic accommodations resulting in lower academic success in the teaching-learning process. However, despite the challenges and limitations faced in activities of daily living among students with disabilities, SWDs have a positive energy and believe they are capable of achieving most activities of daily living.

Another important barrier that students with disabilities face is the negative attitudes that society, colleagues/peers, and family have concerning disability despite the experience of positive attitudes more generally in society, especially in urban settings. Evidence has shown that societal attitudes toward PWD are significant influencers that determine the extent to which the personal, social, educational, and psychological goals of persons with disabilities are realized. If PWD perceive the attitudes of society and peers to be positive, they feel that they are well-integrated into the community [39,40]. However, negative attitudes toward individuals with disabilities can be ‘invisible barriers’ as persons with disabilities pursue community involvement with limited success [41,42]. Participants in the present study discussed stigma and stereotypes that poorly represent persons with disability. Persons with disabilities are often treated with disrespect as it is perceived that they will underperform relative to their peers. Some PWD, are beggars and dependent on others which results in stereotyping, fear, embarrassment, and anger by society about all persons with disabilities. Internalization of discrimination causes a person with a disability to believe that they are less capable than a person without a disability [43]. Participants explained that when negative attitudes from a few people are directed toward PWDs, these prejudices limit the overall engagement of students with disabilities at religious places, parties, and celebrations, regardless of their level of education.

Prior research has shown that increased knowledge of disabilities in conjunction with interaction with individuals with disabilities is the main influential factor in improving societal attitudes towards persons with disabilities [44,45]. The present study found that developing services and building facilities and services to meet the needs of PWDs leads to additional discrimination which results in feelings of rejection and isolation among students with disabilities. However, it also showed an improvement in attitudes over time leading to improved perceptions of persons with disabilities in urban areas over rural areas. Polo Sanchez et al. also found that attitudes in the community have been improving over the years [46].

Accessibility barriers both inside and outside the university campus continue to be a problem for various disability groups (i.e., mobility impaired, upper limb impaired, and visually impaired). The physical infrastructure of buildings within the institution was identified as challenges to students with loss of vision and mobility disabilities, in terms of accessing lecture rooms, toileting requirements, meetings halls, offices, libraries, the hospital or student clinic, cafeterias, space for recreation, and transport to and from the institutions. Almost all facilities were designed in such a way that those who use wheelchairs will find it difficult to access and actually choose where to sit and lack the equipment to enable students with visual disabilities to study maximally.

In addition, student participants face challenges in their daily living with respect to accessing facilities outside the institution like roads, banks, market places, cafeterias, religious places, health care service, public service offices. It has been shown that people with disabilities have significantly less access to services than those without disability, and the barriers reported most often are lack of information, transport, and physical inaccessibility [47,48]. Similar findings are evident in both developing and developed countries where barriers exist for PWD within the setting of transport (public transportation and personal vehicles), building access (obstacles inside university buildings), environmental settings (those elements within the classroom, including furniture), and communication (barriers when accessing information) which have also been found to be inaccessible [49,50].

The final theme was access to assistive technology including the identification of unmet needs and the role of users in the design and development of assistive devices. Finding supported most university students identified with physical disabilities and loss of vision were mainly challenged with poor physical accessibility of institutions; unavailability of educational material in alternative, as opposed to traditional formats; lack of sensitivity and skills of staff; as well as lack of structured support systems [50–52]. Students with disabilities face particular challenges in higher education not only in terms of gaining physical access to buildings, but also in relation to much wider access issues concerning curriculum adaptation and inadequate accommodation, teaching, learning and assessment.

Almost all SWD have access to assistive technology to benefit their education. Other studies have shown the importance of the role of assistive technologies for academic engagement and success, and social participation, resulting in transformative engagement from a psychological perspective [53,54]. The findings of the present study indicated that the white cane, audio recorder, Jaws, braille, eyeglasses, mobile phones and computers were the most commonly assistive technologies used by participants with loss of vision. These devices assisted with recording lectures, writing in all aspects of the university environment, as well as communication and social participation. However, these devices did not necessarily meet all the needs of the students who found that they suffered academically. Ntombela and Soobrayen also identified concern that blind students struggle to access information in some university campuses, a situation that exacerbates barriers to learning and development experienced by students and limits the participation of students with visual disabilities in academic programs [55]. Students with mobility impairments used wheelchairs, prostheses and crutches in navigating their environment. However, those with upper limb impairment have no access to any assistive technology due to the lack of an appropriate device to meet their needs.

Although the impact of AT on the lives of people with disabilities is known, many issues still need to be resolved. Effective design and development of AT is hindered in the current environment which limits engagement in academia and social participation [20,30]. Inadequate AT devices, traveling long distances and the requirement for long-term accommodation within rehabilitation centers during the production and maintenance of assistive devices were some of the issues that frustrated the users in our study. Gilson and Dymond found that unmet needs identified can include poor quality of the assistive devices in terms of durability, capability in assisting functional activities, limited financial capacity, and lack of training during delivery on the use of AT [56]. A study done about AT outcomes and impacts among students with disabilities in higher education shows those with met AT needs had a higher educational engagement, well-being, and academic self-efficacy than those with unmet AT needs [57]. The SWD also worries about future access in which governments do not invest adequately in service provision and training of human resources. Tangcharoensathien et al. also identify similar gaps between product designs and user preferences as well as affordability as being a major barrier in low- and middle-income countries [58].

Limitations

The current study has clarified several important points regarding the challenges that SWDs face daily and their experiences with assistive technology. This has significant implications for addressing the needs of SWDs in general and those with physical disabilities and visual impairments in particular.

This study has also some limitations that need to be considered when the findings are interpreted. For example, the majority of students with disabilities at the University of Gondar were sponsored by the MasterCard Foundation Scholars Program which helps for access to assistive technology and accessibility of the university for persons with disabilities and may not represent the complete picture of access to assistive technology at higher education in Ethiopia. As a result, interpretation of the findings must be made with caution. Another possible drawback of this study could be that while participants were selected from a single Ethiopian university, their experiences could not be representative of students at universities in the country as a whole. Future research should explore students’ perceptions of what AT characteristics are most important in contributing to their psychological, and social well-being and academic achievements in higher education. It is additionally encouraged to conduct more research with people from various universities. We also advise researchers to concentrate on a particular kind of disability, its users’ access to assistive technology, and whether or not their needs for AT are met.

Conclusion

Generally, the present study revealed SWDs are capable of undertaking self-care tasks though each person has different levels of functional limitations depending on the severity and type of impairment, their effective engagement within a classroom environment is affected by their impairment due to barriers. Students with disabilities also experienced both positive and negative attitudes towards people with disabilities despite changing a lot and people living in urban areas have better awareness and positive attitudes toward people with disabilities than those living in rural areas. While some people support PWDs, negative attitudes, stigma, and discrimination toward people with disabilities hinder the quality of life, social participation, and productivity.

Students with disabilities encountered physical barriers to educational services, such as a lack of ramps and/or elevators in multi-level class buildings, heavy doors, inaccessible washrooms, libraries, restrooms, cafeterias, hospitals, offices, and/or inaccessible transportation to and from lecture rooms. Despite many students with disabilities having access to assistive technology, unmet needs for assistive devices persist and multiple barriers have been reported by individuals in accessing needed assistive devices. Many providers have no interest in including end users in the design and production of assistive devices. They rely on generalized predesigned parametric measurements and their understanding of the needs instead of co-designing with the final users of the devices.

The current findings help better understand the challenges in activities of daily living among students with disabilities and their experience in the design and development of assistive technologies. The findings may help policymakers, researchers, and rehabilitators who aim to investigate on a large scale and develop interventions to minimize the challenges and provide rehabilitation support in access, design, and development of assistive technologies. The findings of the present study are needed to support students in higher education for their academic achievement. In addition, this study will help to design appropriate rehabilitation strategies and policies on the accessibility of physical infrastructures, inclusive education, and the provision of assistive technology that meets the needs of users.

Acknowledgments

First, the authors would like to acknowledge MasterCard Foundation for funding this study. We would also like to express our heartfelt appreciation to the University of Gondar, Ethiopia, and Queen’s University, Canada, and also, all data collectors and study participants for their courtesy and cooperation throughout the data collection process.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The authors confirm that the data supporting the findings of this study are available within the article. Reasonable request for additional information on the dataset are available from the principal investigator and corresponding author.

Additional information

Funding

This study has been funded by MasterCard Foundation. However, the funder had no role in designing the study, including data collection, analysis, and interpretation of the findings, manuscript writing, and approval.