assistive technologies assistive technologies for ageing populations in six ... assistive...

Assistive technologies for ageingpopulations in six low-incomeand middle-income countries:a systematic review

Keshini Madara Marasinghe,1 Jostacio Moreno Lapitan,2 Alex Ross2

Additional material ispublished online only. To viewplease visit the journal online(http://dx.doi.org/10.1136/bmjinnov-2015-000065).

1School of Public Health,University of Saskatchewan,Saskatoon, Canada2Innovation for Healthy Ageing,World Health OrganizationCentre for Health Development(WHO Kobe Centre), Kobe,Japan

Correspondence toKeshini Madara Marasinghe,School of Public Health,University of Saskatchewan;madara_m@hotmail.com

Received 17 June 2015Revised 25 July 2015Accepted 3 August 2015Published Online First11 September 2015

To cite: Marasinghe KM,Lapitan JM, Ross A. BMJInnov 2015;1:182195.

ABSTRACTDespite the benefits derived from the use ofassistive technologies (AT), some parts of theworld have minimal or no access to AT. In manylow-income and middle-income countries(LMIC), only 515% of people who require AThave access to them. Rapid demographicchanges will exacerbate this situation aspopulations over 60 years of age, as well asfunctional limitations among older populations,in LMIC are expected to be higher than in high-income countries in the coming years. Givenboth these trends, AT are likely to be in highdemand and provide many benefits to respondto challenges related to healthy and productiveageing. Multiple databases were searched forEnglish literature. Three groups of keywordswere combined: those relating to AT, ageingpopulation and LMIC selected for this study,namely Brazil, Cambodia, Egypt, India, Turkeyand Zimbabwe. These countries are expected tosee the most rapid growth in the 65 and abovepopulation in the coming years. Results indicatethat all countries had AT designed for olderadults with existing impairment and disability,but had limited AT that are designed to preventimpairment and disability among older adultswho do not currently have any disabilities. Allcountries have ratified the UN Convention onthe Rights of Persons with Disabilities.The findings conclude that AT for ageingpopulations have received some attention inLMIC as attested by the limited literature results.Analysis of review findings indicate the need fora comprehensive, integrated health and socialsystem approach to increase the currentavailability of AT for ageing populations inLMIC. These would entail, yet not be limited to,work on: (1) promoting initiatives for low-costAT; (2) awareness raising and capacity buildingon AT; (3) bridging the gap between AT policyand practice; and (4) fostering targetedresearch on AT.

BACKGROUNDAccording to the United NationsDepartment of Economic and SocialAffairs World Population Prospects,Brazil, Cambodia, Egypt, India, Turkeyand Zimbabwe, are expected to see arapid growth in the 65 and above popula-tion in the coming years (see onlinesupplementary appendix A, table 1).Among low-income and middle-incomecountries (LMIC), Brazil, Cambodia,Egypt, India, and Turkey are expected tohave the highest growth in 65 and aboveage group by the year 2050 and 2100within each WHO region (see onlinesupplementary appendix A, table 2).1

Zimbabwe, on the other hand, is expectedto have the second highest growthamong the LMIC in the WHO Region forAfrica (AFRO) by 2050 and thirdhighest by 2100 (see online supplementaryappendix A, table 2).1 In addition torapidly ageing populations, functional lim-itations (activity and participation restric-tions) due to impairment and disabilityamong older populations in LMIC areexpected to be much higher than in high-income countries (HIC). Impairmentis defined by the InternationalClassification of Functioning, Disabilityand Health (ICF) as any loss or abnor-mality of psychological, physiological oranatomical structure or function.2

Disability is defined by the ICF as anyrestriction or lack (resulting from animpairment) of ability to perform anactivity in the manner or within therange considered normal for a humanbeing. With increasing age, older adultsare more likely to experience impair-ment and disability that increase activitylimitations where they may face difficul-ties in executing activities, and

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participation restrictions where they cannot becomeinvolved in social activities.2

For cognitive-related functional limitations, accord-ing to the World Alzheimer Report 2010, the growth innumber of people with dementia in low-income coun-tries is expected to increase from 35 million in 2010to 115 million by 2050, compared to HIC where theincrease is expected to be from 15 million in 2010 toclose to 35 million by 2050.3 In 2012, years livedwith disability (YLDs) due to falls in adults aged 5069in developing countries (66%) was nearly double therate in developed countries (34%).4 Falls have beendocumented as a key health concern leading to YLDsthat older adults are facing today, and occur at home,in institutions and in the community.5

AT are defined as the application of organizedknowledge and skills, procedures and systems relatedto provision of assistive products, whose primarypurpose is to maintain or improve an individualsfunctioning and independence, facilitate participation,and enhance overall well-being and quality of life.6

AT provide significant support and benefits for olderadults in various ways: safety and prevention (ie, pre-vention of falls), mobility and independence, socialconnectivity and ease of living, preservation of cogni-tive abilities, delay in depression, decline in functionalloss and improved well-being and quality of life.713

Safety has consistently been identified as one of themost important reasons for the use of ATamong olderadults.8 10 According to Heywood et al10 home adap-tations have reported a 70% increase in feeling safe athome among older adults, while adaptations such asgrab rails and handrails have been found to producelasting positive consequences. A systematic review byChase et al14 found that AT, home modifications,along with other interventions prevented falls amongcommunity-dwelling older adults. Evidence from thecurrent literature suggest that more than half (62%) ofolder adults felt safer from a risk of an accident withthe availability of even minor adaptations.7 Accordingto a study published by the AARP Foundation in theUnited States of America (USA), home safety devicesmade the majority of older adults feel safer (85%) andgave them peace of mind (78%).7

The definition of AT used in this review includes allthe external technologies or products that aredesigned for and used by older adults. These tech-nologies may assist in carrying out actions (ie,walking, bathing, remembering to take medications)and/or prevent severe health outcomes such as fallsand injuries that may lead to more complicated healthproblems. There is a vast range of AT; according tothe WHO, most of these products can be divided intoseveral classes (table 1).6

AT are a fundamental part of broader, integratedhealth and social system solutions to supportingolder adults. Yet, despite the documented benefitsof AT, some parts of the world have minimal or noaccess to AT that are designed for older adults.According to the WHO, in many LMIC, only 515% of people who require AT have access tothem.15 LMIC are expected to experience the mostrapid and dramatic demographic change, in shor-tened timeframes as compared to higher incomecountries. For example, it took more than 100 yearsfor the share of Frances population aged 65 orolder to double from 7% to 14%,16 whereby it hasbeen estimated that countries like Brazil will takeless than 25 years to reach the same threshold.16

With rapidly ageing populations, accompanied byincreasing functional limitations, in LMIC, AT arelikely to be in higher demand.Given the trends in LMICs, this review investi-

gated the currently available AT, existing enablinglegislation for provision of AT, and initiatives thatpromote AT for older adults in Brazil, Cambodia,Egypt, India, Turkey and Zimbabwe. The objectiveis to explore in the published literature, if currentlyavailable AT and existing legislation related toAT-provision are sufficient to support ageing inplace rather than ageing in institutionalised carehomes; facilitate better health for older adults, espe-cially in terms of functioning and independence (ie,carrying out Activities of Daily Living or ADLs andInstrumental Activities of Daily Living (IADLs));encourage inclusion and full participation in com-munity activities; and enhance older adults overallwell-being and quality of life.

Table 1 Classes of AT

Class Product examples

Products for cognitive functions Memory devices and pill box reminders

Products for sensory functions Spectacles, software for screen magnification and reading, hearing aids

Products related to orthotics and prosth