ASSESSMENT OF EXISTING DISTRIBUTION MECHANISM OF ASSISTIVE MEDICAL DEVICES AND TECHNOLOGY TO PEOPLE WITH DISABILITY (PWD) IN DUBAI, UAE

1. Doctor of Philosophy in Management, Senior Clinical Quality Officer, Corporate Quality Development Office, Primary Health Care Sector, Dubai Health Authority, Dubai, UAE. 2. Consultant, Chief Executive Office, Primary Health Care Sector, Dubai, UAE. 3. Senior Staff Nurse, Health Centers Department, Primary Health Care Sector, Dubai, UAE. 4. Consultant, Head of Quality and Excellence Office, Quality and Excellence Department, Primary Health Care Sector, Dubai Health Authority, Dubai, UAE. 5. Consultant, Chief Executive Officer, Primary Health Care Sector, Dubai Health Authority, Dubai, UAE. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 20 May 2020 Final Accepted: 24 June 2020 Published: July 2020

WHO estimates that over one billion people need one or more assistive products. The mainstream of these are people with disabilities. As people age, including those with disabilities, their function debilities in several areas and hence their necessity for assistive products increases.
As the global population progressively ages and prevalence of non-communicable diseases rises, the number of people needing assistive products is projected to increase to beyond two billion by 2050 [2]. This is likely to place additional burdens on the provision of health care services to this demographic. Many medical devices are available that may benefit elderly people, although these devices may be expensive or may not be available in all countries. These factors impede equitable access to medical devices [3].
Dubai Strategy for people with disability 2015 and Dubai inclusive health policy for people with disability 2018 provided a conducive environment for empowerment of the people with disability it includes AMDT and related services that improve the functioning of people with disability such as communication, mobility, self-care, household tasks, family relationships, public, culture, sport life, education, engagement in play and recreation [4].
The people with disabilities along with the lack of caregiver's coerces AMDT to patronage people in their daily lives. Nowadays, assistive medical device and technology is required mostly by the ( Figure 1) older people, PWD with non-communicable, mental health condition come in many forms and can be used in many ways to support.
1146 Figure 1:-AMDT empowers people to live healthy, productive, independent and dignified lives to participate in education, employment market and civic life. Assistive products and technology can also assist to reduce the need for formal health and support services, long-term care and the work of caregivers. Without assistive products and technology, people may suffer exclusion, and are at risk of isolation, poverty and may become a burden to their family and on society [2]. Example Child with a disability should to play with other children; go to school and be educated; and to become a successful citizen and contributing member of society. It enriches the quality of the life of the people of determination and their families and facilitate them to practice their daily deeds and including them in society while continuing their enjoyment of the highest levels of health, which has the effect of enhancing their overall level of life [5].
Enabling PWD's to remain healthy, active and independent is a priority. This priority first step ( Figure 2) can be attained through increasing the accessibility, acceptability, adaptability, affordability, and availability of high quality AMDT. To ensure this, a first step is to assess the needs and situations of people of disability. The affirmative impact of AMDT goes beyond improving the health and well-being of individuals and their families. There are also socioeconomic benefits to be gained, by virtue of reduced direct health and welfare costs such as recurrent hospital admissions or state benefits and by enabling a more productive labour force, indirectly stimulating economic growth [6].
"Human disability is the lack of progress, survival in place and inability to make achievements. What the determined ones in various fields of achievements have achieved is a proof that determination and will can achieve the impossible and push the person to face all the circumstances and challenges consistently to reach the goals and objectives". (His Highness Sheikh Mohammed bin Rashid Al Maktoum) [7]. UAE healthcare administrators have had considerable interest in innovating and modifying all basic tools and aids that facilitates life for this vital segment of the community, which expected to positively affect the quality of healthcare services [8].
According to Community Development Authority Social Survey 2018, Dubai the estimated prevalence of disability among Emiratis is 3.7 percent (8,952), whereas the Non-Emiratis 2.1% (5,808) [9]. The Dubai household health survey 2014 -study showed that about 13.8% of Emirati (males) are having moderate to severe disability, while 6.9% of non-Emirati (males) are having moderate to severe disability. Approximately 8.5 % population of Dubai have moderate to severe disability as per this statistical survey [10].
Dubai raising up the quality of healthcare services to international best practices by 2021 [11]. In essence, moving in and out of the homes is no longer a problem for PWD in the UAE, which is ahead of several other countries in offering better mobility technology for PWD. Currently, Dubai is introducing modern technologies to help PWD regardless of the severity of their disabilities by designing aids that fit all segments according to engineering studies that have been recognized by leading global manufacturers.
According to UAE ahead in offering better mobility technology for People of Determination, Press Release Dubai October 13, 2019,: Moving in and out of the homes is no longer a problem for People of Determination in the UAE, which is ahead of several other countries in offering better mobility technology for People of Determination. A private national companies have innovated a number of solutions to help People of Determination move around and become self-reliant with better mobility to enable them become one of the community's productive segments and contribute to nation-building [12].
Furthermore, International Exhibition for People with Disabilities, 5-7 Nov 2019, revealed that UAE attempts to benchmark itself against the developed countries as the official authorities stress the importance of integrating PWD in the community and making use of their expertise, while also encouraging them, developing their skills and exploring their talents [12]. However, various factors like the distribution, performance, training; evaluation etc. of AMDT directly affects PWD safety and health. PWD engagement is a key step to ensure of safety and quality [13].

Purpose Of The Study:
The study is carried out with the following objectives to: 1. Understand the gaps in the existing distribution mechanism of AMDT to registered PWD in Primary Healthcare Centers in Dubai. 2. Identify the barriers contributing to equitable access of PWD to AMDT.

Method:-Survey approach:
A survey tool was developed, consisted of demographic information and other questions related to AMDT access and mechanism. In the following areas: 1. Questions relating to using, system and ancillary aspects of AMDT. 2. Training and knowledge of AMDT. 3. Possible barriers, loaning approach. 4. Current use of AMDT 5. Maintenance of AMDT 6. Easy information platform. 7. Recommendation to improve the access and distribution.

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The set of survey questionnaires were designed based on WHO survey of needs for assistive & medical devices for older people in six (6) countries and customized based on region needs [5]. These initial questionnaires circulated through the DHA Disability specialized staff who are working with PWD to test validity and reliability of the tool. The survey questionnaire was finalized after further garner feedback and adopted as the quantitative and qualitative tool.

Building the survey tool-assistive medical devices:
The questions framed around functions deemed most important for PWD in maintaining their independency and then the respondents were asked a series of AMDT related question: 1. Type of functional disability 2. Determining accessibility, acceptability, adaptability, affordability and availability 3. Garner feedback to enhance access to AMDT.

Implementing the survey:
The survey questionnaire was developed in Arabic and English bilingual using Google Form.
Google Form is an open source survey administration app that allows collecting information from users via a personalized survey [14]. Only 459 PWD have participated at 95% confidence level with the margin error of four (4). The online survey linked was open from March 1st to April 30th 2020 i.e. for 2 month duration, in order to capture adequate response. The survey results database was downloaded in full on May, 3rd 2020 for analysis.

Survey analysis:
The raw data was downloaded from the Google Form at the end of the survey period and the quantitative data analyzed using a range of software tools for descriptive statistics, measure of variability method to analysis data as meaningful.
The qualitative data analyzed using inductive, grounded theory [15] for easier and faster manually code open-ended question.

Limitation of the survey:
The survey had limitations that should be considered for interpreting the findings, as well as for planning of future surveys. 1. There were very few respondents reflecting their perceptions of end-user beliefs for some questions.
2. The small number of respondent meant that one has to be cautious in generalizing from the findings. When conducting any type of research it is beneficial to carry out the research on a larger and more in-depth scale in order to allow a more comprehensive analysis of the study. There were good response received and provided very useful information and meaningful data however, sample size should be increased to get more response.

Results:-
AMDT are products and allied health services that significantly affect the functioning of PWD and their safety which led to increase in their satisfaction level. In essence, AMDT enables PWDs to live healthy, productive, and independent allow them to participate in several civic life activities [16].
Findings show that the respondents' characteristics have been broken down into five main groups, which are gender, nationality, marital status, occupation and level of education. In total, 459 users and caregivers were involved in this 1149 study (the sample included both males and females), where 285 were females (61.6 percent) while males were 174 (38.4 percent).
There are several reasons for the high percentage of female respondents in this study, because the majority of the sample of caregivers in this study has been taken from clinics where most of the employees are females. In Dubai Health Authority, most of the staff working in the clinics are females female patients tend to accept females particularly in pediatric and gynecology specialist clinics where most of the patients are females and children.
Regarding nationality, the sample consisted of 98.6 percent Emirati and 1.3 percent non-Emirati. The higher proportion of Emirati participants was attributed to the fact that the study was conducted in the public sector, where a high proportion of Emirati patients have health insurance; hence, they receive free treatment.
Concerning the distribution of participants by marital status, findings show that the majority of the respondents 54.6 percent were married. Regarding education level, 8.5 percent of the participants had bachelor degrees, and about 9.6 percent had high school certificates. Further results were close to 69.5 percent of the participants were students and 21.1 percent of they were retired.
However, this indicates that the study succeeded in reaching people with diverse linguistic and socioeconomic backgrounds. Concerning the usage of assistive device among PWD, results revealed that the majority of participants 68.9 percent were using AMDT.

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Among the device users 35 percent of them were collaborating with DHA for AMDT while 20 percent were getting them from other Ministries, authorities and organizations such as MOCD, MOHAP, CDA, charity organizations, youth clubs, where as 45 percent obtain their AMDT by other means.
The results also showed the DHA's user and caregivers 84.1 percent received their services through DHA home care services, where the majority of them 48.6 percent were traveling less than 10 Kilometers to receive the required AMDT.
In an attempt to interpret the results, the extracted factors were assigned labels. "Training on using assistive medical device technology" and "device maintenance" were two of the study's factors that had two items, and the findings revealed that the majority of the users and caregivers 66.5 percent were received training on using AMDT. 1151 49.1 percent of AMDT maintenance were provided by device provider. These results indicate that the users and caregivers had have a required training on how to use the AMDT, and that device provider conducted regular maintenance sessions. Notably, For PWD, AMDT is the lifeline that provides them access to and control over their environment including the home, school and greater community. AMDT frequently represents their sole means by which to communicate, learn, develop social relationships, and benefit from school and life experiences. In addition to the provision of devices and strategies, training in the use of AMDT must also be provided to ensure effective and successful outcomes.
The results further revealed that about 59.2 percent of the participants were using their AMDT for more than 10 years, 53 percent of participants stated that AMDT actually helping them to live independently. This indicate that they had a good level of experience in using them and that they were gotten a considerable outcome from using AMDT.
Study Results showed that about 65 percent of AMDT cost was covered by themselves, while only 30 percent sponsored by charity organization and insurance schemes collectively.

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The results also denoted to the fact that the users and caregivers strongly declare and believe that high cost 54.9 percent, lack of funding 36.2 percent, lack of knowledge of obtaining process 22 percent and long insurance approval were main barriers to get right AMDT.
In addition, the results indicated that the majority of respondents 43.5 percent agreed that borrowing AMDT for short period would not be helpful, whereas 36.4 percent of respondent's supported borrowing AMDT for short period of time to reduce waiting time [17]. Furthermore, the users and caregivers were preferred to get information about the availability of AMDT through various channels such as through SMS 75.7 percent and Mobile Application 42.8 percent.
The results revealed that the majority of the participants 61.1 percent were satisfied with the current process of obtaining AMDT where 29.4 percent of them were dissatisfied.

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Finally, the grounded theory with manual coding results have identified the need for the government to develop AMDT process, which provides free AMDT or funding/Insurance coverage for AMDT and provide training to PWD.

Conclusions:-
The survey underlines the methodology, provided expedient information in identifying the gaps, barriers and use of Assistive Medical Device and Technology in support of PWD. The survey was efficacious in obtaining useful information for the 12 Primary Health Centers in Dubai. A list of priority needs for AMDT distribution to meet consistent functional activity in PWD was produced and can be used as the basis for further discussion.
The grounded theory and descriptive statistics revealed noteworthy recommendation that AMDT approval process shall be seamless, smart and cost shall be covered under insurance and charity organization to eliminate barriers. Recommending physician/therapist/organization shall cognizant PWD and family members on AMDT obtaining process and training on usage and maintenance process.
The governance have to develop AMDT distribution mechanism to ensure equitable accessibility, availability and affordability through insurance and charity organizations. Support distribution mechanism to update implement, monitor and evaluate AMDT process is one area with enormous potential for better access and distribution to improve quality of life, mobility and independency [18] and common strategies to reduce disability [19].