A total of forty-one participants took part in this study. Thirty two in the in-depth interviews and 9 in the participatory mapping exercise. The demographics characteristics of the in-depth interviews are described in detail elsewhere . To protect the confidentiality of the participants we only provide the overall demographic characteristics: all but one participant lived in Envigado, 7 were women and 6 had a physical impairment. Figure 2 shows the results of the asset mapping exercise.
Main themes identified in the in-depth interviews included: the meaning of rehabilitation, challenges to access services such as barriers to personal mobility, perceptions and knowledge on disability, and navigating the system, and community participation . These themes informed the design of the guiding questions of the participatory mapping exercise.
Overall, participants in the participatory mapping exercise identified a series of factors at the personal, interpersonal, community, and system levels that limited access and use of assets in the community (Figure 3). Only rehabilitation professionals mentioned that the lack of individual disability awareness and self-acceptance hinders the enjoyment and use of community assets. This personal factor was not mentioned by the group of people with disabilities.
Both people with disabilities and rehabilitation professionals indicated that the mapping exercise made them realize that they visited several places in their day-to-day life and acknowledged the vast amount of physical barriers to access an asset in their community. Assets identified in the community included places related to health (providers facilities), sports and recreation (theaters, shopping malls, stadiums, gyms, bars and restaurants, public parks), public services (city hall, notary services, banks), private buildings (one’s home and family/friends home), religious worship places, education, and grocery stores. Only rehabilitation providers mentioned banks and notaries and one person with disability mentioned the airport. Most of the assets were in Envigado (suburban) except specialized health care services that were in Medellin (urban).
Participants acknowledged that there are accessibility efforts at the community level; however, people’s attitudes and behaviors hinder the use of assets by people with disabilities. There may be accessible public spaces, but the inappropriate use of the space by others in the community makes them inaccessible. An example is when vehicles are parked blocking sidewalks curb cuts. Testimonies in both groups depict community accessibility measures that fail to facilitate the enjoyment of assets:
“Now that we are talking about San Rafael hospital, there is a ramp but it is too steep, making it very difficult to go up” [Male, PWD].
“To enter the theater there are a lot of stairs, there is a stair lift but it only fits one person...if you go with a group of people that needs the lift...how long do you have to wait?..it also needs to be operated by someone from the theater, resulting in prolonged waiting times to access” [Female, rehabilitation professional]
Interactions between the factors exacerbate the barrier(s) experienced at any given level, resulting in exclusion. In situations when people apparently have access to assets in their communities, the existing barriers result in not using them at all. For example, one of the rehabilitation professionals that also lives with a disability quit school because classes were at night and it was dangerous for him going back home on his wheelchair on the road: “Last semester was very hard, it was at night (classes) and that is why I quit school...going back home rolling...more than one (car) will honk on me…and raining” [Male, Rehabilitation professional]. In some cases, people with disabilities simply do not leave their homes as sorting out the barriers is too complex. This is reflected in the experiences of participants in both groups:
“I’m a soccer fan, here is difficult to enter the stadium. They let me in; but, I have to be at the lawn by myself….So I stopped going and now I watch the games by myself at home. All my family goes to the stadium and I have to stay behind at home” [Female, PWD]
Interaction of factors at different levels to access and use community assets
Enjoying and using assets in their communities (i.e. participating) is determined by the ability to simultaneously manage factors at different levels. Strategies to overcome situations that result from the interaction of factors at different levels from both groups were abundant. We provide and discuss examples for each levels, as follows.
Personal-Interpersonal: the lack of an accessible home and an appropriate wheelchair increases the need for assistance and financial resources as it requires extra costs (e.g. paying someone for assistance to leave the home or to get to the asset of interest).
““I prefer the church that is closer to my home...when it is not raining and my two sons are at home...I’m happy that they take my power wheelchair and I can go by myself to church...My daughter can’t take it down, it is too heavy...” [Female, PWD]
The accessibility of the community access does not suffice, if the person with a disability needs support from another individual, the time when the asset needs to be used must coincide when the time that the support person is available: “I stopped going to a micro-enterprise course because the person that goes with me can’t always go...if she can’t go with me, I have to pay for transport...expenses are higher than income...people believe that it is just a matter of enrolling in an activity...but you have to do more things than that…” [Female, PWD]
A similar case was described by a professional who did a home visit that week:
“...That person’s home has the worse accessibility, a 5th floor, no elevator and no ramp...two relatives have to leave work early once a week to carry him up and down the stairs in his wheelchair so he goes out” [Female, Rehabilitation professional].
Interactions between personal factors such as living situation and interpersonal factors such as an assistant’s support result in hindered participation.
Personal-Community: Lack of accessible and reliable public transportation may increase the need for financial resources (e.g. to pay a taxi), to have extra time (e.g. not knowing when the accessible bus comes through the bus stop) or having to roll long distances to get to the asset of interest.
“There are some public buses with accessibility [a lift for wheelchairs], not all of the buses have and we do not know with what frequency they run. This forces me to pay for taxi, I can’t be late for an appointment and I can’t go rolling” [Female, Rehabilitation professional]
Lack of physical accessibility in routes to get to an asset requires advanced wheelchair mobility skills to navigate obstacles. When reflecting on the effect that lack of physical accessibility has on the participation of wheelchair users, only rehabilitation professionals mentioned that to be able to access assets, wheelchair users must learn advanced wheelchair mobility skills. As described by a male rehabilitation professional:
“I usually roll [the manual wheelchair] on the street....accessible sidewalks...very few...even the new ones that we evaluated the other day are too high and do not have a curb cut”. [Male, Rehabilitation professional]
In this specific case the participant is able to overcome the physical obstacles because he has advanced wheelchair mobility skills. In the discussion about community assets related to leisure and culture, one provider stressed:
“We have the house-museum...to get there...people definitely need to learn how to maneuver their wheelchairs [the entrance is through a gravel parking lot]” [Female, Rehabilitation professional]
Lack of accessible facilities, including restrooms, require the person to plan or overcome extra logistics (e.g. identifying an accessible restroom that may be at a different floor and taking longer routes to avoid obstacles). Lack of accessible and continuous pathways to go from one place to another may result in the person having to take more risks (e.g. roll the wheelchair on the street with the cars and motorcycles, having to be lifted by others up/down curbs or stairs).
“The Nueva EPS [health center] has a mini ramp, but the doctors’ offices are in the second floor. That is why they have to see you downstairs…” [Female, Rehabilitation professional]
Participants acknowledged that there is progress and that some public spaces in Envigado have been undergoing accessibility interventions. During the mapping exercise, both people with disabilities and rehabilitation professionals discussed the underlying reasons for the contextual barriers and ideas to tackle the root problems. Lack of disability and accessibility awareness was mentioned by both groups. In the words of one participant:
“...the problem is culture and the fact that people that are in charge, our governors and city mayors...that they know about planning so when a new building is going to be designed…you know, when people visit other countries they come back saying that there a lot of people in wheelchairs...and it is not that...the thing there is that people with disabilities live a normal life, they are not stuck at home and they have accessibility for everything...here we see a person with a disability and we have to tie them to a rope like Tarzan…” [Female, PWD].
Educating others on disability awareness and accessibility was mentioned as an urgent strategy needed. Lack of disability awareness results in exclusion as explained by a participant with a disability:
“I think it is better that the parking spots for PWD are marked with a cone...even if you have a difficulty to get off the car to move the cone...you can scream, ask someone the favor…, if the cone is not there, people will use it...really, the problem is the citizen’s culture...including thinking that the PWD is only the wheelchair user”…[Female, PWD]
The rehabilitation professionals had done an experiential exercise with public officials from the municipality and shared:
“We did an awareness exercise with officers from public infrastructure development...we crossed a light - we had them use wheelchairs - one of them was in the middle of the crossing when the light changed to red..cars honked...this person later called the people in charge to inquire why the duration of the green pedestrian light was so short” [Male rehabilitation professional].
Personal-Community-System: limited mention to current policy as an influential factor were present. Only one mentioned a specific case to use legal appeal (tutela mechanism in Colombia) to drive change: “Some fellow students are going to help me to legally appeal so the university’s accessibility is fixed” [Male, Rehabilitation professional].
The above mentioned results were jointly presented by researchers and study participants to a group of stakeholders in Envigado, including study participants, who volunteered to be part of this activity. Figure 3 illustrates an example presented during the community forum to depict the different levels of barriers that a person with a mobility impairment may encounter when trying to reach to a community asset. There was a general consensus among the forum participants that the interaction between the factors influence their enjoyment of community assets. Stakeholders at the community forum brainstormed on actionable aspects to improve the enjoyment of community assets under equal conditions. Examples include to increase disability awareness in academia as a strategy to emphasize that accessibility is needed to achieve personal autonomy. In addition, a need for information about the public buses routes and the need for information on where people with disabilities live in Envigado was highlighted. Coordinated actions between the local government, academia, people with disabilities, and other organizations was mentioned as a needed strategy to overcome the hindering factors at the different levels. Last, at the personal level, there needs to be a focus on the individual’s responsibility to accept the disability as a factors imperative to reach participation.