The psychological distress and positive mental health of people with physical impairments & their families: Kampong Cham province in Cambodia 2015. By Krittika Vongkiatkajorn

08 Fall

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TableofContents1. Executivesummaryofthestudyfindings........................................................52. Introductiontothecontext(includingtheliteraturereview)..................6Introduction............................................................................................................................6StudyObjective.......................................................................................................................6OverviewofTheSocialModel.............................................................................................7OverviewoftheDisabilityCreationProcess..................................................................7OverviewofMentalHealth................................................................................................10OverviewofTheKhmerRogue.........................................................................................12Disability-Statistics..................................................................................................................................13TypesofImpairments..............................................................................................................................13Disability–LandmineInjuries.............................................................................................................14WomenwithDisabilities.........................................................................................................................15CarersofPeoplewithDisabilities......................................................................................................16Disability–MentalDisorders...............................................................................................................17

Disability–CulturalConstruction&LivedExperience.............................................17Introduction...................................................................................................................................................17Disability–HealthConstruct................................................................................................................18Disability–ReligiousConstruct..........................................................................................................18Disability–LabourConstruction........................................................................................................19

DisabilityServices...............................................................................................................20RehabilitationServices............................................................................................................................20Non-governmentorganizations(NGOs).........................................................................................20

OverviewofMentalHealth................................................................................................21Introduction...................................................................................................................................................21MentalDisorders.........................................................................................................................................21NeurologicalDisorders............................................................................................................................22PsychologicalDistress..............................................................................................................................23PositiveMentalHealth.............................................................................................................................23

MentalHealth–LivedExperience...................................................................................24MentalHealth–CulturalConstruction............................................................................................24MentalDisorders–CulturallyExperienced..................................................................................25

MentalHealthServicesOverview....................................................................................25Introduction...................................................................................................................................................25MultidimensionalHealthCare.............................................................................................................26WesternService...........................................................................................................................................27DeterminantsofCare................................................................................................................................28

OverviewBarriers...............................................................................................................28Poverty-Disability....................................................................................................................................29Poverty–MentalHealth..........................................................................................................................30

3. Studymethodology..............................................................................................31StudyObjective.....................................................................................................................31MixedMethodApproach....................................................................................................31SelectionandSamplingMethods.....................................................................................32QualitativeDataCollection................................................................................................32LiteratureReview.......................................................................................................................................32FocusGroupDiscussions........................................................................................................................32Semi-structuredin-depthinterviews...............................................................................................34

QuantitativeDataCollection.............................................................................................34Survey...............................................................................................................................................................34

LimitationsoftheResearch..............................................................................................34

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4.QuantitativeFindings.............................................................................................35Demographics.......................................................................................................................35Part2:Disability...................................................................................................................36Part3:Definitionofhappiness.........................................................................................36Part4:Generalfeelingsinlife..........................................................................................37Part4a:Confidencebeforeandafterdisability...........................................................38Part5:Depression,AnxietyandStressScore.DAS-21..............................................38Part6:Impactonlife...........................................................................................................39Part6.a:Impactonsocialrelationships........................................................................39Part6.b:Typesofdiscrimination....................................................................................39Part6.c:Impactonexpectations......................................................................................40Part6.d:Impactonfamily.................................................................................................40Part7:Services.....................................................................................................................40Part7a:Servicesthatcontributetopositivementalhealth....................................41Part7b:Locationofservices.............................................................................................41Part8:FutureServices.......................................................................................................42

5.QualitativeFindings................................................................................................42Peoplewithphysicalimpairmentsandtheirfamilies...............................................421. Theunderstandingofhealthandwell-beingwithintheKhmercontext.............422. Howsadness,depression,distressanxiety(psychologicaldistress)effectivepeoplewithphysicalimpairmentsandtheirfamilies?...........................................................433. Thepositivementalhealth(optimism,self-esteem)ofpeoplewithphysicalimpairmentsandtheirfamilies...........................................................................................................484. Toidentifyhowpsychologicaldistressandpositivementalhealthaffectbarriersandfacilitatorstoservices..................................................................................................49

Community.............................................................................................................................505. Thecommunityunderstandingofpsychologicaldistressandpositivementalhealth................................................................................................................................................................506. Whatisthecommunityresponsetopeoplewithphysicalimpairments?...........507. Theroleofthecommunityineffectingbarriersandfacilitatorstoservices.....51

ServiceProviders&Stakeholders...................................................................................518. Thestakeholdersunderstandingofpsychologicaldistressandpositivementalhealth................................................................................................................................................................519. Towhatextentdoespsychologicaldistressandpositivementalhealthaffectbarriersandfacilitatorstoservicesforpeoplewithphysicalimpairmentsandtheirfamilies?...........................................................................................................................................................53Whoarethestakeholders,whataretheirapproachesandexperienceswithdealingwithpeoplewithphysicalimpairments?.......................................................................................54a. Thecurrentmentalhealthservicesexisting,arethoseservicesaccessible&inclusiveofpeoplewithphysicalimpairments?........................................................................55b. Whataretheexistingbarrierspeoplewithphysicalimpairmentsandtheirfamiliesfaceinaccessingservicese.g.physical,attitudes,practices,policies?.........55

Discussiononadditionalfindingsandconclusions...................................................56Macro:CollectiveWellBeing................................................................................................................56Macro:Lackofrightsforpeoplewithdisabilities.....................................................................57Macro:Institutional&AttitudinalBarrier.....................................................................................57Mezzo:TheConceptofPity&AttitudinalBarrier.....................................................................58Macro:Unemployment............................................................................................................................59Mezzo:Community&AttitudinalBarrier......................................................................................60Mezzo:Community&Discrimination..............................................................................................61Mezzo:RolesandResponsibility........................................................................................................61Mezzo:Lackofeducation........................................................................................................................62Micro:Dailylivingexperiences...........................................................................................................62

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Micro:Carers.................................................................................................................................................62Micro:Family................................................................................................................................................63PositiveMentalHealth.............................................................................................................................64PsychologicalDistress..............................................................................................................................65

6.Recommendations..................................................................................................66Recommendationsbasedonliteraturereview...........................................................66ResearchImplications-PsychosocialIssues..............................................................................66ResearchImplications-LivedExperiences.................................................................................66ResearchImplications-BarriersToServices.............................................................................67ResearchImplications:RecoveryFramework.............................................................................67ResearchImplications:CulturalSensitiveFramework...........................................................68ResearchImplications:IntegratedServices.................................................................................69

Recommendationsbasedonstudyfindings.................................................................691. EducationonmentalhealthbyserviceprovidersincludingLouvainCorporation...........................................................................................................................692. Educationondisability(DisabilityCreationProcess)byServiceProvidersincludingHandicapInternational...................................................................................703. Educationonrightsforpeoplewithdisabilities(SocialModel)byServiceprovidersincludingHandicapInternational...............................................................704.Advocacyandawareness(EducationalandCommunityLevel)byserviceprovidersandthecommunity..........................................................................................715.TrainingbyNGOsbyserviceproviders,especiallyHandicapInternationalandLouvainCooperation...........................................................................................................716.Inclusionofpeoplewithdisabilitiesinallprocessesbyallserviceprovidersandthecommunity..............................................................................................................727.Peer&FamilyModelbyserviceproviders...............................................................728.Integratedservicesduringdesignandimplementationbyserviceprovidersandcommunityleaders......................................................................................................7210.BetteraccessibilityforPeoplewithDisabilitiesbyserviceproviers.............7310.Research..........................................................................................................................73

7.Appendix....................................................................................................................83Appendix1.............................................................................................................................83Appendix2.............................................................................................................................85Appendix3.............................................................................................................................87Appendix4.............................................................................................................................89Appendix5.............................................................................................................................96Appendix6..........................................................................................................................109Appendix7..........................................................................................................................121Appendix8..........................................................................................................................134

7.Listofpersonsmetduringthestudyprocessandsalientpointsofthemeetings......................................................................................................................145

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1. ExecutivesummaryofthestudyfindingsHealthandwell-beingwithintheKhmercontext,istohaveafunctionalbodyandtolivewithinahygienicenvironment.Despiteparticipantsbeingabletoidentifysomesymptomsofpsychologicaldistress,thereisminimalunderstandingofmentalwell-beingacrossallkeystakeholdersincludingpeoplewithdisabilitiesthemselves,familymembersandcarerscommunitymembersandleadersandkeyserviceproviders.

Disabilityremainspredominantlyviewedthroughthemedicallensasasymptomtobefixed.PeoplewithdisabilitiesareperceivedasobjectsofpityandthecharitymodelremainstheunderlyingframeworkofdisabilityinCambodia.ThesocialmodelofdisabilityinCambodiaremainsrudimentaryandtherightsofpeoplewithdisabilitiesremainlargelyunrecognized.GovernmentlawsandpoliciesforpeoplewithdisabilitiesaccordingtotheUnitedNationsConventionontheRightsofPersonswithDisabilities(UNCRPD)areunevenlyupheldbynon-governmentorganizationsandgovernmentinvolvementremainsminimal.

Peoplewithphysicalimpairmentsandtheirfamiliesexperiencesignificantpsychologicaldistressasaresultofavarietyofinternalandexternalfactors.Thesemainlyincludelackoflivelihood,pooraccessibility,socialexclusion,stigmaanddiscrimination,familyconflictandthelackofemployment.Additionally,thelevelofphysicalimpairmentisamajordeterminantofthedegreeofpsychologicaldistress.Thestudieshavefoundthatmenwithcongenitaldisabilityandthosewhohavehadroadtrafficaccidentsdisplayedgreatersignsofpsychologicaldistress.Womenwithdisabilitiesandcarersfacesubstantialdomesticviolenceandabusewithinthefamilyanddisplayhighlevelsofpsychologicaldistress.

Bothcommunitymembersandserviceprovidershaveaminimalunderstandingonthelivedexperiencesofpeoplewithdisabilitiesandtheirfamilies.However,thecommunitywasidentifiedasamajorsourceofpsychologicaldistressandpositivementalhealth.Significantstigmaanddiscriminationhasbeenidentifiedashappeningmostlywithinthecommunity.However,respondentsidentifiedhavingrelationshipsandreceivinginformalencouragementasparamountfortheirself-esteemandoptimism.ServiceprovidershaveidentifiedtheirlackofknowledgeofworkingwithpeoplewithdisabilitiesandexpresstheneedforfurthertrainingandhaveidentifiedNGOsastheexpertiseinthearea.

Thereisaclearneedforfurthereducationonmentalhealthandondisabilitybyallkeystakeholders.Additionally,peoplewithdisabilitiesandtheirfamiliesrequireassistancethatinvolvesbothsocialandpsychologicalassistance.

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Therefore,futureservicesshouldconsideranintegratedapproach,whichaddressesbothinternalandexternalbarriers,whichareinterdependenttopsychologicaldistress.Lastly,thereneedstobecontinuedeffortinraisingawarenessfortherightsofpeoplewithdisabilitiesinthepublicandprivatesectorandforwomenwithdisabilitiesandcarers.

2. Introductiontothecontext(includingtheliteraturereview)

IntroductionPeoplewithdisabilitiesareoneofthemostmarginalizedanddisadvantagedgroupsintheworld(Palmer,2011).Landmineinjuries,roadtrafficaccidents,diseaseandcongenitaldisabilityallcontributetomakingCambodiathehighestnumberofdisabilitypercapitaintheworld(Carter,2009;Gartrell&Hoban,2013;Jegannathan,Kullgren,&Deva,2015).Despitebeingthemostrapidgrowing,post-conflicteconomyintheworld,thisdevelopmentremainsunsustainableandsignificantlyimpededbythehighnumberofpeoplelivingwithadisability(Cantor-Graae,Chak,Sunbaunat,Jarl,&Larsson,2014;Durham&Hoy,2013;Morgan&Tan,2011;Stockwell,Whiteford,Townsend,&Stewart,2005;Vanleit,2008;WorldHealthOrganization,2011;Zimmer,2006).Poorsocialandeconomicinfrastructurecreateextremelyvulnerableanddisablingenvironmentforthosewhosufferfromphysicalimpairments(Seponski,Lewis,&Megginson,2014).Asaresult,individualswithaphysicaldisabilityandtheirfamiliesexperienceexponentialbarrierstoservicesandhavehigherpsychosocialneeds(Gartrell,2010;Mollica,Brooks,Tor,Lopes-Cardozo,&Silove,2014;Palmer,2011).Despitesomevolumeofliteratureexaminingthementalhealthofthosesufferingfromlandmineinjuries,therehasbeenverylittleresearchonthepsychosocialneedsofpeoplewithothertypesofcausesofphysicalimpairmentandtheirfamilies(Cantor-Graae,etal.,2014;Mollica,etal.,2014).

StudyObjectiveTherefore,thisliteraturereviewaimstoachievethreemajorobjectives.

• Firstly,tounderstandandidentifythepsychosocialneedsofpeoplewithphysicalimpairments;

• Secondly,todevelopanunderstandingofthelivedexperiencesofindividualswhohavephysicalimpairments,theircarer’sandfamily;and

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• Lastly,considerhowtheneedsofpeoplewithphysical impairmentsaremet as well as outline existing barriers to psychosocial health serviceprovision.

OverviewoftheSocialModelPriortothesocialmodelofdisability,themedicalandcharitymodelsawpeoplewithdisabilitiesasamedicalproblemtobefixedorindividualstobepitied(HandicapInternational2012).However,thesocialmodelunderpinnedbytheUNCRPDemphasizescitizenship,access,choice,participation,positiveself-image,sharedresponsibilityandaccountabilitybyallkeystakeholders(HandicapInternational2012).Transitionphrasemission:peoplewithdisabilitiesaredisadvantagenotbecauseoftheirindividualcharacteristicbutasaresultoflimitationimposedonthembytheenvironment&externalbarriersItisimportanttorecognizethedifferencebetweenthehumanrightsmodelwhichemphasizesthatpeoplewithdisabilitiespossesscivil,economicandsocialrights(WorldHealthOrganization,2011).However,thesocialmodelidentifiesthatpeoplewithdisabilitiesexperiencethreetypesofbarriersincluding,institutional,environmentalandattitudinalbarriers(HandicapInternational,2009).

Firstly,institutionalbarriersincludesthelackofpolicyandlegislationtoensurethatpeoplewithdisabilitiesareabletofullyparticipateinsociety(HandicapInternational,2009).Secondly,environmentalbarriersconsidersthelackofphysicalinfrastructuresuchasinaccessiblebuildingsthatpreventaccesstoservicesandsignificantlifeopportunities(HandicapInternational,2009).Lastly,attitudinalbarriersexistwithinpeople’sattitudesandpreconceptionswhichcausesstigmaanddiscriminationagainstpeoplewithdisabilities(HandicapInternational,2009).Thesocialmodeldoesnotnegatethemedicalneedsofpeoplewithdisabilities,butallowsthemtotakeownershipoftheirlivesandputsthematthecenteroftreatmentratherfocusonlyontheimpairment(HandicapInternational&FrenchAgencyforDevelopment,2015;Hughes,2010).Theultimategoalofthesocialmodelistomaximizetherightsofpeoplewithdisabilitiesandensureequalopportunity(Hughes,2010).Additionally,thisreportwillfollowthemajorshiftinlanguageasaresultofthesocialmodelfrom“disabledpersons”to“peoplewithdisabilities”(HandicapInternational&FrenchAgencyforDevelopment,2015).ThesocialmodelwasacrucialfoundationforthedevelopmentoftheDisabilityCreationProcessusedbyHandicapInternational.

OverviewoftheDisabilityCreationProcess

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Theterm“impairment”isunderstoodas“theactuallossoffunctionsinanindividualcausedbyaninjuryorillnesswhichcanbecongenitaloracquiredlaterinlife”(HandicapInternational,2012).Animpairmentmaybephysical,intellectual,sensoryormental(HandicapInternational,2012).Whereasdisabilityis“theresultoftheinteractionbetweenthepersonswithimpairmentandattitudinalandenvironmentalbarriersthathindertheirfullandeffectiveparticipationinsocietyonanequalbasiswithothers”(HandicapInternational,2009).Thisviewhighlightsthedifferentdefinitionofimpairmenttodisabilityandthesocietalandenvironmentalbarriersthatpreventsthefullparticipationofpeoplewithdisabilitiesinsociety(HandicapInternational,2012;UnitedNationsDevelopmentProgramme,2015;WorldHealthOrganization,2011).Notwithstandingthemedicalmodel,theaimoftheDCPistoemphasisenvironmentalfactors,effectivelyaddressstigmaandbreakthepovertyanddisabilitycycle(Gartrell&Hoban,2013;Parnesetal.,2009;WorldHealthOrganization,2011).Therefore,everyattempttoreduceadisabilityshouldbeactiondirectedtowardssocietalandenvironmentalfactorsratherthanthepersonwiththedisability.TheDisabilityCreationProcess(DCP)isacomprehensiveframeworkdevelopedbytheQuebecclassificationofdisabilityandusedbyHandicapInternationaltoprovideathoroughunderstandingofdisability.Specifically,theDCPexamineshowpersonalfactorsandtheexternalenvironment,interacttocauseadisabilitywithinanindividual’slife(HandicapInternational2012).Additionally,themodelallowsforagreaterappreciationoftheevolvingnatureofdisabilityandisusedasacomprehensivetooltoassistpeoplewithdisabilitiesandtheirfamiliesinovercomingtheirdisability.Itisanadaptationofthehumandevelopmentmodelintheareaofdisability.Itusesthecentralnotionofsocialparticipationasresultingfrominteractionbetweenpersonalfactorsandenvironmentalfactors.Theinteractionbetweenpersonalandenvironmentalfactorscanlimitthefullrealizationofaperson’slifehabits.TheDCPdevelopedandusedbyHandicapInternationaldrewuponthethreemajortheoreticalfoundationsincludingtheDCPinCanada,theInternationalClassificationofFunctioning,DisabilityandHealth(ICF)bytheWorldHealthOrganizationandthedefinitionofdisabilityaccordingtotheUnitedNationsConventionontheRightsofPersonswithDisability(UNCPRD)(HandicapInternational2012).

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TheDisabilityCreationProcess

The“riskfactor”consistsofanelementwithinanindividual’slifeandwithintheenvironmentthatmaycontributetodeteriorationintheperson’sdevelopmentorphysicalfunctioning(HandicapInternational2012).Anexampleofariskfactorelementwithinaperson’slifeandtheenvironmentcouldbealcoholaddictionandpoortrafficcontrol.Whentheseriskfactorseventuatetheyareconsidereda“cause”ofimpairment(HandicapInternational2012).The“personalfactors”consistoftheindividual’suniquecharacteristicssuchasage,genderandsocioculturalidentity(HandicapInternational2012).Organic

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systemsandaptitudearetwomajorcategoriesthatmakeuppersonalfactors(HandicapInternational2012).Organicsystemsencompassthebodycomponentsincludingthemuscularsystems,skeletonsystemandocularsystems(HandicapInternational2012).Incontrast,aptitudeisthepossibilityofanindividualtoaccomplishaphysicalormentalactivity,whichcanincludelanguageabilityandotherskills(Handicap2012).“Environmentalfactors”includeanysocialorphysicalaspectswithinthesurroundingenvironmentorcontextthatcanimpactlifehabits(HandicapInternational2012).Socialaspectsmayincludepolitical-economicfactorsorsocio-culturalfactors(HandicapInternational2012).However,physicalaspectsincludethingssuchasarchitecturaldesignornature(HandicapInternational2012).Therearetwomajoraspectstoenvironmentalfactorsincludingfacilitatorsandobstacles.Specifically,facilitatorsarethingsthatpromotelifehabitswhereasobstacles(barriers)arethings,whichhindertheactualizationoflifehabits(HandicapInternational2012).“Lifehabits”aretheeverydayactivitiesorasocialidentitythatismaintainedbytheindividualaccordingtotheirsocio-culturalcontextandcharacteristicssuchasage,gender,personalcareandidentity(HandicapInternational2012).Lifehabitseventuatetoensureanindividual’swell-beingandsurvivalthroughouttheirlife(HandicapInternational2012).Yet,lifehabitscaneitherbecategorizedassocialparticipationandadisablingsituation(HandicapInternational2012).Socialparticipationincludesthefullrealizationofone’slifehabits(HandicapInternational2012).Incontrast,adisablingsituationconsistsofonlypartialornon-realizationofone’slifehabits(HandicapInternational2012).An“interaction”isthepointwherepersonalfactors,environmentalfactorsandlifehabitsmeetandinfluenceoneanotherandcreatesadisability(HandicapInternational2012).Additionally,theinteractionbetweenthesethreefactorsisdynamic,complexandalwaysshiftingaccordingtothechangewithinkeydimensionschange(HandicapInternational2012).Theculminationofinstitutional,attitudinalandenvironmentalbarriers,hinderthesociallifeofpeoplewithimpairments,whichleadtoasituationofdisability.Asaresult,peoplewithdisabilitiesarevulnerabletoarangeofmentalhealthissues.Thisstudyaimstoidentifythebarriersandfacilitatorsinsocietythatwilleffectivelyaddresstherightsofpeoplewithdisabilitiesbeincludedincivilsociety.

OverviewofMentalHealthTheterm“mentalhealth”includesthreeoverarchingcategoriesincludingpsychologicaldistress,mentalhealthdisordersorillness,andpositivementalhealth(HandicapInternational,2011).

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HandicapInternational’s(HI)definitionofmentalhealthincludespsychologicaldistress,mentaldisordersandpositivementalhealth.LinkedtoWHOdefinition,itisunderstoodthatphysicalandmentalhealthareinterdependentandisnotdefinedbytheabsenceofdisease(HandicapInternational,2011).Forthepurposesofthisstudy,psychologicaldistressandpositivementalhealthwillbetheprimaryfocus,whereasmentalhealthdisorderswillbeomitted.Thereasonforomittingmentalhealthdisorderswithinthisresearchwastoensurethescopewasnottoolarge,andsecondlythatHIaredealingprimarilyintheRehabilitationCentrewithissuesofpsychologicaldistressandwellbeing.Psychologicaldistressisa“stateofdisquietwhichisnotnecessarilysymptomaticofapathologyormentaldisorder”(HandicapInternational,2011).Itincludespeoplesufferingfromdisablinginjuriesandtraumas”(HandicapInternational,2011).However,itisthepresenceofnon-severeortemporary,symptomsofpsychologicaltrauma,anxietyanddepressionwhichdonotmeetthecriteriafordiagnosingmentaldisorders(HandicapInternational,2011).Psychologicaldistressesareareactiontostressfulsituationssuchasmigration,exile,naturaldisaster,existentialdifficulties(HandicapInternational,2011).“Thistypeofdistressdoesnotnecessarilyleadtotheonsetofmentaldisorderandisnotpathologicalbutcanbesevereenoughtowarrantitsinclusioninanegativedefinition”(HandicapInternational,2011).

Psychologiccaldistress•Whenpsychologicaldistresshasasocialcauseitisknownas"psychosocialsuffering"orsociallycaused"mentalsuffering".

MentalDisorders•Referstodisordersassessed

withadiagnosticcriteriawhichrequirestherapeuticaction.Thisalsomustbeaccompaniedbyavariabledurationandameasurementofseverity.I.edepression,schizophrenia,paranoia.

PositiveMentalHealth• Stateofwell-being• Afeelingofhappinessand/orself-fulfillment• Personalitytraitssuchasresilience,optimism,abilyttodealwithdifficulties,feelingofcontroloverone'slife,self-esteem)

MENTALHEALTH

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MentaldisorderswhichconsistsofamentaldiagnosisaccordingtotheDiagnosticandStatisticalManualofMentalDisorders(DSM-5)ortheInternationalClassificationofDiseases(ICD-10)(HandicapInternational,2011).Anexampleofthiscanincludediagnosissuchasclinicaldepression,psychosis,anxietypersonalitydisorders,schizophreniaorparanoia(HandicapInternational,2011).

Positivementalhealthreferstothe“eithertoastateofwell-being,afeelingofhappinessand/orself-fulfillmentortopersonalitytraitssuchasresilience,optimism,abilitytodealwithdifficulties,feelingofcontroloverone’slifeandself-esteem”(HandicapInternational,2011).“Thisisapositivestateofbalanceandharmonybetweenthestructuresoftheindividualandthoseoftheenvironmenttheyhavetoadaptto”(HandicapInternational,2011).Mentalhealthandpsychologicaldistressmayleadtoa“psychosocialdisability”.Thecausesofapsychosocialdisabilitymayincludepoverty,homelessness,abreakdownwithinthefamilyandsocialrelationshipsandunemployment(HandicapInternational,2011).Whenthesesituationsadverselyaffectthesociallife,socialskillsandtheirabilitytotakecareofoneself,thisshouldbeconsideredasapsychosocialdisability(HandicapInternational,2011).Specifically,thelossofthesecapacitiesmayhinderthecapacityintermsofbehavior,language,intellectualactivities,theabilitytoprotectoneselfortoaskforassistance(HandicapInternational,2011).Thisstudywillattempttoidentityriskfactorsthatcouldleadtoapsychosocialdisability.

OverviewoftheKhmerRougeAnestimationoftwomillionpeopleoraquarterofthepopulationinCambodiawerekilledduringtheKhmerRouge(McLaughlin,2012).Specifically,theKhmerRougedestroyedsignificantcivilinfrastructureincludingthejustice,healthandeducationsystem(McLaughlin,2012).ThisdevastationcausedbytheKhmerRougehashadasignificantnegativeimpactontheeconomy,societyandphysicalandpsychologicalhealthofCambodians(Cardozoetal.,2012;Hein,2015;Mollica,etal.,2014;Seponski,etal.,2014).

ItisimportanttorecognizethatpsychologicaldistresscanbetransmittedtothecurrentpopulationandthefuturegenerationevenaftertheKhmerRouge(McLaughlin,2012).PhysicalimpairmentscausedmylandminesplantedduringthewarmightrelatesomepsychologicaldistressasaresultoftheKhmerRouge(McLaughlin,2012).DespitetheconnectionbetweenlandminesandtheKhmerRouge,manyauthorsrecognizethatmuchofthepsychologicaldistressand

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mentaldisordersofCambodiansarecausedbypoverty,violenceandthelackofhumanrights(Jegannathan,etal.,2015;McLaughlin,2012).However,thisreviewrecognizestheinfluenceoftheKhmerRougebutiscautiousthatitisnotthesoleresponsibility,norshoulditovershadowotherpresentdayinfluencesthatcontributestothepsychologicaldistressofpeoplewithphysicalimpairments(McLaughlin,2012).

Disability-StatisticsRecentyearshasshowntheofficialprevalenceusedbytheRoyalGovernmentofCambodiaofpeoplewithdisabilitiesinCambodiais4%(HandicapInternationalFrance,2009).Yet,theAsianDevelopmentBankarguesthat9.8%isamoreaccuratestatistic(Cordier,2014;Zook,2010).Howeverin2012CambodianSocio-EconomicSurveyestimatedthedisabilityprevalencerateinCambodiaat5%(NationalInstituteofStatisticsMinistryofPlanning,2013).Additionally,itisestimatedthatbetween10.1%and15.6%ofchildrenage2-9yearsoldhaveadisabilityandanimpairmentrespectively(HandicapInternational,2011/2012).ItisimportanttoconsiderthattheWorldDisabilityReportstatesthattheprevalenceofpeoplewithdisabilitiesindevelopingcountriesarebetween10%-15%oftheglobalpopulation(WorldHealthOrganization,2011).Asaconsequenceofsignificantdiscrepanciesindata,manyauthorsarecautiousonthestatisticsofpeoplewithdisabilitiesinCambodiaandsuspectthattheactualdataremainsignificantlyunderreportedandinconsistent(Cordier,2014;Palmer,2011;Zook,2010).

Amajorreasontothislackofdataremainsthedifficultyinobtainingdataofthoselivinginruralandremoteareas(Mollica,etal.,2014;Zook,2010).Ithasbeenidentifiedthatthemajorityofpeoplelivingwithadisabilityarelocatedinruralareasandarehighlylikelyexcludedfrommajordatacollection(Palmer,2011).Moreover,authorspointoutthatcensusdataisalsoseverelyskewedasitonlycapturesquestionsthatrelatetosevereimpairments(Palmer,2011).Discrepancyanddoubleupofdatacollectionwasalsohighlightedasanotherproblemduetothecoexistingdisabilitiessuchas“deaf-mute”incensusdata(Durham&Hoy,2013).Itisalsoarguedthatmostinternationalliteraturehasbeenlimitedtothesehospitaldatabasesandthosewhoareunregisteredremainexcludedfromdata(Bendinelli,2009;Durham&Hoy,2013).Asaresult,neithercensusdatanorpeer-reviewedjournalsareabletopresentaclearviewofthenumberofpeoplewithdisabilitiesinCambodia(Mollica,etal.,2014;Palmer,2011).

TypesofImpairments

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Peoplewithvisualimpairmentremainthehighestnumberofpeopleexperiencingadisabilityat30%(HandicapInternationalFrance,2009).Thisisfollowedby23.5%ofpeoplewithamobilityimpairmentand15%ofpeopleexperiencingahearingdifficulty(HandicapInternationalFrance,2009).However,thelargestcausesofimpairmentincludesoldage(26.7%),disease(25.8%),accidents(11.4%)andcongenital(8.7%)(Gartrell&Hoban,2013;HandicapInternationalFrance,2009).PovertyandinaccessibilityremainthedominantsocialdeterminantofdisabilityinCambodia(Carter,2009).Yet,over50%ofallcausesofdisabilityinCambodiaarepreventable(Carter,2009).

AmputeesasaresultoflandminesinjuriesarethelargestcategoryofpeoplewithphysicalimpairmentsinCambodia(Durham&Hoy,2013).Consequently,itisnotunreasonablethatasubstantialvolumeofstudieshasrevolvedaroundthistypeofinjury(Bendinelli,2009;Mollica,etal.,2014;Zook,2010).However,thereareagrowingnumberofpeoplewithparaplegiacausedbygunshotsandroadtrafficaccidents(Durham&Hoy,2013;Parnes,etal.,2009).Despiteasubstantialvolumeofresearch,thequalityofdataremainsrelativelyinadequatetoidentifythepsychosocialneedsandtotallongtermimpactofthephysicalimpairmentsinCambodia(Mollica,etal.,2014).

Aminimalamountofliteratureadequatelyaddressesintellectualandcognitiveimpairments(Jegannathan,etal.,2015).Asaresultofthelackofresearch,peoplewithamentalandintellectualimpairmentremainsthemostpoorlyservedwithinthecommunityofpeoplewithdisabilitiesandlackthemostinfrastructureandservices(HandicapInternational,2011).Similarlypeoplewithspeech,visualandhearingimpairments,remainsunder-researched(Palmer,2011).However,forthepurposesofthisresearch,therewillbealargeremphasisonthelivedexperiencesofthosewhophysicalimpairments.

Disability–LandmineInjuries Studieshaveidentifiedthatthepatternofinjuriessuchlandmineinjuriesarecorrelatedtospecificlocationsasaresultofwar(Durham&Hoy,2013).Antipersonnellandmineswereusedtostrategicallycreatelargewoundsandpermanentlongtermdisability(Bendinelli,2009).EstimatesfromtheLandmineMonitorReport2011bytheInternationalCampaigntoBanLandmines(2011)evaluatesthataround648.8km2oflandinCambodiaiscontaminatedwithunexplodedordnance(UXO)andexplosivesremnantsofwar(ERW).Inotherwords,thereareapproximatelyover10millionantipersonnellandminesinCambodia(Durham&Hoy,2013;Gartrell&Hoban,2013;WorldHealthOrganization,2011).Furthermore,thesecontaminatedareasarelocatedinmostimpoverishedandruralareaswhere80%ofcivilianslivewithextremelypoorhealth(Durham&Hoy,2013;Gartrell&Hoban,2013).Asaresult,themost

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vulnerablepopulationinCambodiaareatthehighestriskofobtainingalandmineinjury(Durham&Hoy,2013;Gartrell&Hoban,2013).Intheeventofaninjury,hospitalsaremostlyinaccessibleandbeyondthemeansforthesevictims(Bendinelli,2009).Thereisalargedifferencebetweenthephysicalinjuriesobtainedbylandmineinjuriesbetweenchildrentoadults(Bendinelli,2009).Themajorityoflandmineinjuriesweremoreassociatedwithmalewhowerepronetoexplorethefields(Durham&Hoy,2013;Mollica,etal.,2014).Amongmen,acommonpatternshowedthatadultshadasignificantlyhighernumberoflowerlimbinjuriesrangingfrom28%to39%whencomparedto27%to28%torsoinjuriesand5%to31%visionloss(Bendinelli,2009;Cardozo,etal.,2012;Durham&Hoy,2013).However,thatchildrenhadinjuriesintheupperbody,mostlyheadinjuries,neck,upperlimbs,trunkinjuries,visionlossandbilateralblindnessduetolandmineinjuriesandexplosivesremnantsofwar(Bendinelli,2009).Therehasalsobeendatathatshowsthatfemalesandchildrenareexperiencingahigherrateoflandmineinjuries(Bendinelli,2009).Amajorreasonisthelargerfemaleandchildrenpopulationafterthewar(Bendinelli,2009).Itisimportanttonotethatthelargestphysicalimpairmentamongchildreniscerebralpalsy(Bachanietal.,2011).Despitesignificantstatistics,thesedatalackimplicationsonthelongtermeffectsandcostsofthedisabilitywhichisdetrimentaltohighlightingthesignificanceoftheissueforpolicychange(Bendinelli,2009).

WomenwithDisabilities

Cambodiabelongstogroupofcountrieswiththelowestgenderinequalityindexintheworld(UnitedNationsDevelopmentProgramCambodia,2010).Itisestimatedthatbetween20%-25%ofwomeninCambodiaexperiencedomesticviolence(McLaughlin,2012).However,womenwithdisabilitiesexperiencessignificantlymoreabuseandviolationsoftheirhumanrightssetoutbytheUNCRPDandtheOptionalProtocol(UnitedNations,2006,2009).

WomenwithdisabilitiesinCambodiaareathigherriskexploitation,stigmaandviolence(Astbury&Walji,2014;Parnes,etal.,2009).Specifically,womenwithdisabilitiesinCambodiaexperiencesignificantabuse,neglect,disdainandhavetheleastaccesstohealthcare(Astbury&Walji,2014).Additionally,thisstudyfoundthatwomenwithdisabilitywerevulnerabletopsychological(43.8%),physical(18.4%)andsexualabuse(4.2%)(Astbury&Walji,2014).Specifically,psychologicalviolencecanincludecoercivecontrolsuchasrestrictingtherightstoeducation,seekinghelpandaccessinghealthcare(Astbury&Walji,2014).Consequently,womenwithdisabilitiesinCambodiapossesslowerratesofliteracyandincomeandareexcludedfromaccesstoeducationandhealthcare(Astbury&Walji,2014;UnitedNationsDevelopmentProgramCambodia,2010).

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Physicalviolencemayincludethepurposefulremovalandintentionaldamagetotheiraids,equipmentandmobility(Astbury&Walji,2014).Additionally,intenseformsofphysicalviolencesuchasstabbing,shooting,orthrowingacidonwomenremainsacceptableintheeventofadisagreementoranargumentwiththeirpartners(Astbury&Walji,2014).Duetosignificantrisksofabuse,around28%ofwomenwithdisabilitydonotattendschool,¾areunlikelytogetmarriedandmostwillcontinuewiththeirbirthfamily(Astbury&Walji,2014).

Despitethefactthatwomenwithdisabilityexperienceviolence2½moretimes,over57%ofwomenwithdisabilitydonotinformothersofabuseorseekhelpfromavailableservices(Astbury&Walji,2014).Asaresult,violenceaswellasdisabilityexacerbatesthelevelofmentaldisordersincludingdepression,anxiety,posttraumaticstressdisorder(PTSD),andsuicideideation(Astbury&Walji,2014).Therefore,womenwithdisabilitiesmustberecognizedasmuchmorevulnerable,stigmatizedandexcludedwhencomparedtowomenwithoutdisabilitiesandpeoplewithphysicaldisabilities(Zook,2010).

CarersofPeoplewithDisabilitiesTheWorldHealthOrganization(WHO)predictsthatby2050therewillbeanincreasebetween115%-581%incarersofpeoplewithdisabilitiesintheGlobalSouth(Cordier,2014).SpecifictoSouthEastAsiancultures,thecareofachildoradultwithdisabilitiesinCambodiaisunpaid,timeconsuming,rigorousandmayrequirealifetimecommitment(Cordier,2014).However,ithasbeenestimatedthat80%ofcarer’sarewomenincluding,themother,sister,wivesorgrandmotherofthepersonwithadisability(Cordier,2014).AsimilarstudyofpeoplewithadisabilityinNorthEastThailandfoundthatthecareofpersonswithdisabilitiestoassociatedtothefamilyratherthantothesociety(King&King,2011).Oftenthecarermayalsoexperiencearolereversalandbecomethebreadwinner(King&King,2011).Specifically,thecarerwillneedtofindasourceofincomebutalsoensuresufficientfinancesfortreatmentandongoingrehabilitation(King&King,2011).Insomecases,womenmaychoosetoleavetheirhusbandswithadisabilityinordertoseekanotherindividualwhoisabletoprovidefortheirneeds(King&King,2011).Theseunpaidcarer’sexperiencelimitedassistancefromthegovernmentandarelackingtherequiredtrainingandsupport(Cordier,2014).

Incircumstanceswherethecarermustworktoprovideanincometheymayleavethepersonwithadisabilityathomealone(King&King,2011).Often,thecarer’scapabilitiesareextendedbeyondtheirabilitytoprovideeffectivecareforothersandthemselves(Cordier,2014).Additionally,carersmayexperience

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stigmatizationanddiscriminationasaresultoftakingcareofthepeoplewithdisabilities(HandicapInternational,2011).Itisalsopossiblethatcarersarepartlyblamedforthedisabilitythathasoccurred(King&King,2011).Thesevereshortageofliteratureregardingthepsychosocialissuesofcarersdemandscriticalattentionandfurtherinvestigation.

Disability–MentalDisordersOnlyonestudyspecificallyexaminedthecorrelationbetweenadisabilitycausedbyalandmineinjuryandthepsychosocialoutcomes(Cardozo,etal.,2012).Thisstudyfocusedonarangeofmentaldisordersbutalsopsychosocialdeterminantstopositivementalhealth(Cardozo,etal.,2012).Theresultsfromthestudyshowedthat74%ofpeoplewithdepressionoftenhavevisionimpairments,experiencedmultipletraumaticeventsandtorture(Cardozo,etal.,2012).Incontrast,62%ofpeoplewhoexperiencedanxietywerethosewhohadtorsoinjuries(Cardozo,etal.,2012).Lastly,37%ofpeoplewithPTSDwerethosewhohadlostahighernumberoflimbsduetolandminesandhaveexperiencedtorture(Cardozo,etal.,2012).Intermsofpositivementalhealth,thestudyfoundthat“empowerment”,i.e.findingmeaningandbeinginvolvedinsocialactivitieshadabeneficialimpactonthepsychosocialwellbeingofpeoplewithdisabilities(Cardozo,etal.,2012).Specifically,thisincludedhavinganeducation,earninganincome,belongingtoareligiousorinvolvementwithapoliticalparty(Cardozo,etal.,2012).Incontrast,ruminationandavoidanceregardingtheinjury,associatedpainandreceivingspecialassistance,increasedtheratesofdepressionandanxiety(Cardozo,etal.,2012).Itisimportanttonotethatthereisagrowingamountofinternationalliteraturewhichhasfoundthatanxietyanddepressionhaveaseriouseffectonphysicalfunctioning,socialskillsandlaborcapacity(Duboisetal.,2004).Thisindicatesthepotentialofapsychosocialdisabilitybutrequiresfurtherresearch.

Inconclusion,thestudyshowedthatthelevelofmentaldisordersweresignificanthigherwiththosewhohaveadisabilitywhichhasbeencausedasaresultoflandmines(Cardozo,etal.,2012).Althoughthisstudywasoneofthefirsttobeconducted,themajorweaknessofthestudyremainsexclusivelyintheprovinceofSiemReap(Cardozo,etal.,2012).Therefore,similarandlargerworkisneededacrossothertypesofimpairmentsanditotherareasofCambodia.

Disability–CulturalConstruction&LivedExperience

IntroductionPresently,peoplewithdisabilitiesinCambodiaareviewedasindividualstobepitiedandhelpedthroughcharityfromgovernments,thecommunityandnon-

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governmentorganizations(NGOs)(Gartrell&Hoban,2013).Bothsocialnormsandreligiousbeliefscreatebarriersatthemicro,mezzoandmacrolevelforpeoplewithdisabilities(Durham&Hoy,2013;Palmer,2011;Parnes,etal.,2009;Seponski,etal.,2014;Zimmer,2006;Zook,2010).Asaresultofthelackofahumanrightsbasedapproach,peoplewithdisabilitiesfacesubstantialdiscrimination,arestigmatizedandaresociallyandeconomicallymarginalized(Cordier,2014).

Disability–HealthConstruct

Individualswithacongenitaldisabilityfacetwogeneralassumptions(Gartrell,2010;Gartrell&Hoban,2013).Itisassumedthatdisabilityiscausedasaresultofthelackofvaccinations,poorinternalhealthandpoornutritionalhealthduringpregnancy(Gartrell,2010;Gartrell&Hoban,2013).Theliteratureshowsapatternthatpeoplewithdisabilitiesareassociatedwithhavingabraindamageorashavingnervedamage(Gartrell,2010;Gartrell&Hoban,2013;Palmer,2011).Itisarguedthatthisidearesultedfromtheerraticandunusualbehaviordemonstratedbypeoplewithdisabilities(Gartrell,2010).Thispromotesanimagethatpeoplewithcongenitaldisabilityareconsideredtobeuseless,untrustworthy,unabletolearnandwithoutanysignificantvalue(Gartrell,2010;Gartrell&Hoban,2013;Palmer,2011).

Thebeliefinkarmaalsoplaysanimportantpartonthelivedexperiencesofpeoplewithdisabilities,althoughit’sinfluenceismoreassociatedtoaphysicalimpairmentthatisobtainedlaterinlife(Bachani,etal.,2011;Gartrell&Hoban,2013).Thesebeliefsenhancetheviewthatpeoplewithdisabilitiesareemotionallyunstable,immature,lacksocialskillsandshouldbeexcludedinimportantdecisionmaking(Gartrell,2010).Asresultofsignificantstigma,peoplewithdisabilitiesfacediscriminationonmultipleinstitutionallevelsandespeciallywhentryingtoobtainloans(Gartrell,2010).

Disability–ReligiousConstructTheravadaBuddhismisthemainreligioninCambodiaand85%ofpopulationholdthisbelief(Carter,2009).LiteraturehighlightsthatidentifyingtheinfluenceofBuddhismtoeverydaystigmaisagrossoversimplificationofthelivedexperiencesofpeoplewithdisabilities(Carter,2009).Religionisinterconnectwithcultureandplaysamajorinfluenceinshapinghowdisabilityisunderstood,perceivedandmanagedinCambodia(Carter,2009).Ashavingadisabilityhassignificantconnotationswithkarma,theassociatedstigmahasimplicationsonaidfundingallocation,theconstructionofstigma,thetraditionofpityandtheestablishmentofsocialhierarchies(Carter,2009).Religiousdiscriminationagainstpeoplewithdisabilitiesisexperiencedacrossthecommunity,localandnationallevel(Carter,2009).Insummary,someliteraturearguesthatreligion

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infusedstigmasystematicallyexcludespeoplewithdisabilitiesfromthefundamentalaspectsofcitizenshipandequalsocialmembershipinCambodia(Gartrell,2010).

Disability–LaborConstructionCambodia’sgrowingeconomyandworkforceisonethatrequiressignificantphysicallaborandmanpower(Gartrell&Hoban,2013;Palmer,2011).Consequently,ethnographicresearchfoundthathavingadisabilitycontributestothelossoflaborpowerandhouseholdincome(Gartrell,2010).Similarly,peoplewithdisabilitiesinThailandareconsideredonlyasvaluableastheirabilitytobeproductive(King&King,2011).Asaresult,peoplewithdisabilitiesareconsideredaburdentosocietyanddevaluedamongtheircounterparts(King&King,2011).Specifically,peoplewithdisabilitiesareconsideredasunabletoparticipateinreciprocalrelationshipsthatcontributetothewelfareofthefamily(Carter,2009;Cordier,2014;Gartrell,2010;Vanleit,2008).Yet,itisestimatedthatthecostofexcludingpeoplewithdisabilitiesfromemploymentcancostupto7%ofthegrossdomesticproductforlowincomecountriessuchasCambodia(Buckup,2009;Sæbønesetal.,2015).Thisfigureisconsideredanunderstatementasitdoesnotconsiderthefinanciallossofthefamily(Buckup,2009;Sæbønes,etal.,2015).Therefore,furthersignificanceshouldbeplacedontheimpactofunemploymentandunderemploymentofpeoplewithdisabilitiestotheeconomyofCambodia(Buckup,2009;Sæbønes,etal.,2015).

Ithasbeenfoundthatthegeneralpopulationassociatepeoplewithdisabilitiesasonlycapableofbeggingandaredependentuponthegoodwillandpityofothers(Gartrell,2010).Additionally,manypeoplewithdisabilitiesareunderemployedandrestrictedtopoorlypaidwork(Gartrell,2010).Asaresultofattitudinalbarriers,peoplewithdisabilitiesareexcludedfromeducation,work,employmentandcivillife(Gartrell&Hoban,2013).Authorsarguethatdiscriminationagainstemploymentremainsoneofthesubtlestyetmostinescapableofalltypesofinequalitiesfacedbypeoplewithdisabilities(Bhallaetal.,2013;Gartrell&Hoban,2013).Studieshavefoundthatpeoplewithdisabilitiesbelievethatthemostappropriatesolutiontotheirproblemsistocontributetotheirhouseholdworkandfinances(Gartrell&Hoban,2013).AstudyonculturalnormsinCambodiafoundthatsuccessfulpeoplewithoutdisabilitiesareconsideredtobein“bigwork”,whichimpliespower,statusandrespect(Gartrell,2010;Gartrell&Hoban,2013).Whereaspeoplewithdisabilitiesaresociallyconfinedto“smallwork”,ormenialjobssuchascookingandcleaning(Gartrell,2010).Incircumstanceswherepeoplewithdisabilitiesarerestrictedto“smallwork”suchaschildcare,cooking,cleaning,orcollectingfirewood,theyarecategorizedas

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havethelowestworkingvalueinsociety(Gartrell,2010).Asaresult,theresearchrevealedthatpeoplewithdisabilitieswhohavesubstantialachievement,areperceivedasathreatandadisruptiontosocialhierarchiesandculturalnorms(Gartrell,2010).Specifically,peoplewithdisabilitieschallengethecurrentrelationshipassociatedwith“bigwork”andphysicalability(Gartrell,2010;Gartrell&Hoban,2013).Therefore,theviewofpeoplewithdisabilitiesinCambodiaremainsnarrowlyfocusedontheirnegativelimitationsandinabilitytocontributeandparticipateinsociety(Gartrell,2010).

DisabilitySpecificServices

RehabilitationServices

OnestudyidentifiedthatservicestowardsdisabilityinCambodiaremainspredominantlyskewedtotowardsphysicalrehabilitation(Zook,2010).Inreviewingtheliterature,theauthorfoundaseriesofsignificantfactorsthatcontributetothisbiasincluding,alackofknowledgeofothertypesimpairments,theabsenceofqualifiedphysicianstotreatotherimpairmentsandtheinsufficientadvocacyofotherdisabilitiesforpolicyreform(Zook,2010).Thestudyalsorecognizedthatthesamewordfor“rehabilitation”inKhmerisalsousedwithcriminals(Zook,2010).Consequently,thisconnotationimpliesthatpeoplewithdisabilitiesareseenasaproblemtobefixedwhichcontinuestoreinforcethemedicalmodelofdisability(Zook,2010).Therefore,theauthorhighlightsthatpeoplewithdisabilitiesmayfacefurtherstigmatizationasaresultofaccessingrehabilitationservices(Zook,2010).

Non-governmentorganizations(NGOs)ThemajorityofliteratureidentifiedprogramsforpeoplewithdisabilitiesaspredominantlyrunbyinternationalNGOswithminimalsupportfromtheCambodiangovernment(Astbury&Walji,2014;Gartrell&Hoban,2013;Zook,2010).However,someauthorsemphasizedthatmanyinternationallyfundedprogramsoftenlackculturalsensitiveandreinforces“pity”anddisempowerspeoplewithdisabilities(Gartrell&Hoban,2013).Morerecentattentionhasbeenfocusedonthelackofaninclusionofpeoplewithdisabilitiesinthedesignofprogramsandpolicies(Gartrell&Hoban,2013).RecentstudieshavefoundthatsocialenterprisesinitiatedbyNGOsoftenfailandexacerbatefurtherstigma(Gartrell&Hoban,2013).Therefore,authorschallengetheroleofNGOsashavingthepotentialtoreinforcereliance,dependenceandpassivity(Gartrell&Hoban,2013).However,therearereportsofrecentrightsbasedandinclusiveprogramsthatpromotetheinvolvementofpeoplewithdisabilitiesinprogramdesignandimplementation(Gartrell&Hoban,2013;Zook,2010).

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Theaimfortheseprogramsemphasizetheintegrationofpeoplewithdisabilitiesandothersinthecommunitytoreinforcenormality,asenseofdignity,meaningandself-respectforpeoplewithdisabilities(Zook,2010).AconsiderableamountofliteratureemphasizethatNGOservicesarerequiredtodevelopagreaterunderstandingofthebarriersandstigmapeoplewithdisabilitiesfaces(Astbury&Walji,2014).Consequently,servicesmustminimizethesebarriersandbecomesensitivetothefactthatthatpeoplewithdisabilitieshavedifficultyarticulatingneedsandovercomingmultidimensionalbarriersthemselves(Astbury&Walji,2014;Gartrell&Hoban,2013).Thelargevolumeofliteraturehighlightsthelimitedamountofcollaborationbetweenformalhelpwithnon-formalhelp,whichdiminishthepotentialtomaximizeattitudinalandbehavioralchangesatthevillageandcommunitylevel(Astbury&Walji,2014).Inconclusion,servicesforpeoplewithdisabilitiesremainpredominantlyrunbyNGOsbutparticularattentionmustbepaidtoprocessesthatincludepeoplewithdisabilitiesateverylevel.

OverviewofMentalHealth

IntroductionThereisalargevolumeofpublishedstudiesdescribingpoormentalhealthasasignificantstrainonthesocial,economicanddevelopmentalgrowthofCambodia(Cantor-Graae,etal.,2014;Cardozo,etal.,2012;Hein,2015;Seponski,etal.,2014).Internationalliteratureclaimsthatasaresultofunevendistributionoffundsinlow-incomecountries,90%ofthosesufferingfrompoormentalhealthreceive10%oftheavailablementalhealthresources(Seponski,etal.,2014;WorldHealthOrganization,2011).SeveralrecentstudiesonthenationalhealthbudgetinCambodia,foundthatbetween0.02%to1%(approximately$30,000perannum)ofthetotalhealthbudgethasbeenallocatedtomentalhealth(McLaughlin,2012;Schunertetal.,2012).Anotherstudyhighlightedthatthereisanestimationof0.23psychologistsper100,000peopletomeetthementalhealthneedsinCambodia(Astbury&Walji,2014).Fromthesefindings,itisclearthatmentalhealthhasbeenseverelyneglectedissueinCambodia.

MentalDisordersThefirstresearchontheprevalenceofmentaldisordersinCambodiawasconductedbyDuboisetal.(2004)onasampleof1,320peopleagedover20yearsintheprovinceofKampongCham.Thisstudyshowedthat,42.4%oftherespondentsreportedsymptomsthatmettheDSM-IVcriteriafordepressionand7.3%thecriteriaforPTSD,53%presentedsymptomaticanxietysymptomsasdefinedbyHSCL-25.Regardingsocialfunctioning,25.3%presentedsocialimpairmentduetoahealthconditionoranemotionalcondition.AmorerecentandlargerstudywasconductedbytheDepartmentofPsychologyattheRoyal

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PhnomPenhUniversity(Schunert,etal.,2012).Thestudyfoundthattherewasahigherlevelofmentaldisordersamongfemaleandmalechildren,respectivelyaggression(11.5%),childabuse(10%-8%)andsuicide(0.8%)(Schunert,etal.,2012).ThesuiciderateofchildrenandadolescenceinCambodiais2.6timeshigherthantheaveragenumberofsuicidesglobally(Schunert,etal.,2012).Probablementaldisordersrangingfromthehighesttolowestincludedanxiety(31.7%female/18.4%male),depression(19.7%female/10.2%male),PTSD(3.1%female/1.4%male)andschizophrenia(0.6%female/0.2%male)(McLaughlin,2012;Schunert,etal.,2012).

Thekeyfindingsofthestudyfoundthatchildrenandwomenexperiencedasignificantlyhighlevelofmentaldisorders(Schunert,etal.,2012).Despitebeingthefirstlargescaleresearch,cautionisadvisedwheninterpretingthedataasthereweretwomajorlimitationstothisstudy.Firstly,therewasanoverpresentationoffemaleparticipantsduetothelackofmaleparticipantsduringtheharvestseason(Schunert,etal.,2012).Secondly,asnoclinicalexaminationstookplaceduringthedatacollection,theprevalenceofmentaldisordersonlyremainsprobable(Schunert,etal.,2012).Asaresult,thesefindingsdonotconfirmtheactualnumberofpeoplewithmentaldisordersinCambodia.

TheonlyfactualdataoftheprevalenceofmentaldisorderinCambodiawascollectedin1999andexclusivelywithinanoutpatientandclinicalsetting(Jegannathan,etal.,2015;Somasundaram,vandePut,Eisenbruch,&deJong,1999).Thisdataindicatesthatthemostcommonformsofmentaldisordersincluding18%ofpeoplesufferingfromanxiety,18%ofschizophrenia,15%fromepilepsyand15%ofpsychosis(Jegannathan,etal.,2015;Somasundaram,etal.,1999).However,otherformsofmentaldisordersincludeorganicpsychosis(4%),PTSD(3%),mania(3%),somatization(2%),intellectualdisability(2%)andothertypes(5%)(Somasundaram,etal.,1999).However,boththestudybytheRoyalUniversityofPhnomPenhandthestudybySomasundaram,etal.,(1999)alsofoundthatwomenpossessedahigherdegreeofmentaldisorderswhencomparedtomen.Incomparisontothehighernumberofmalepatientsexpectedinpsychiatricclinicsacrosstheglobe,thementalhealthofwomeninCambodiarequiresparticularattention(Schunert,etal.,2012;Somasundaram,etal.,1999).Bothstudiesinferthatwomenwillcontinuetobethelargestgrouprequiringmentalhealthservices(Schunert,etal.,2012;Somasundaram,etal.,1999).ApossiblereasonforthisstatementisthehighlevelofviolencethatwomenwithCambodiaexperiencesuchasintenseformsofphysicalviolenceanddomesticviolence(Astbury&Walji,2014).

NeurologicalDisorders

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Emergingresearchhasfoundthattraumasymptomslessonovertimeandotherpsychologicalsymptomssuchasmooddisorderscantakeprecedent(Cantor-Graae,etal.,2014;Jegannathan,etal.,2015).Jegannathan(2015)arguesthatmentalhealthresearchinCambodiaisovertlytraumafocused.Morerecentliteraturehashighlightedthatothermentalhealthproblemsandneurologicaldisordersincludinganxiety,mooddisorders,psychosis,attentiondeficithyperactivitydisorders,seizuredisordersandautismareequallygaininggroundinCambodia(Jegannathan,etal.,2015;Zook,2010).SupportingthisviewisthejointreportbyWorldHealthOrganization(WHO)andHandicapInternationalindicatingthatneurologicaldisordersarethemostconcerningpathologiesinthe21stcentury(HandicapInternational,2011).Additionally,forecastsofneurologicaldisordersareestimatedtoincreaseby50%by2020(HandicapInternational,2011).

PsychologicalDistress

Agreatdealofliteratureonpsychologicaldistresshasfocusedonaddressingpovertyanddiscriminationasmajorcontributors(Jegannathan,etal.,2015;Palmer,2011;Seponski,etal.,2014).Specifically,theresearchfoundthattheunequaldistributionofresourcesespeciallyinlowincomecountriesandthelackaofhumanrightsmodelhadanegativeeffectonmentalhealth(Seponski,etal.,2014).Asaresultinthelackofmaterialforbasicneeds,povertywasprolongedandcontinuedtoexacerbatepoormentalhealth(Seponski,etal.,2014).Thiscanincludethelackofshelter,food,accesstoeducationandhealthcareandbasicmentalhealthneeds(Seponski,etal.,2014).Socialfactorssuchasthelackofbasicneeds,financialworry,familywelfare,socioeconomicinsecurity,humanresourceconstraintsandintimatepartnerviolencealsocontributetosignificantpsychologicaldistress(Cantor-Graae,etal.,2014;Jegannathan,etal.,2015).However,recentstudieshavebegunhighlightingtheimportanceofunderstandingcyclicallifeevents,thecontextoffamilyandtheinfluenceofpoverty,warandnaturaldisastersonpsychologicaldistress(Seponski,etal.,2014).Asaresult,lifeeventsasaresultofextremepovertymustbeconsidered,asitisamajorcontributortolongtermtraumaandsignificantpsychologicaldistress(Seponski,etal.,2014)

PositiveMentalHealth

Thereremainsverylittlestudiesonpositivementalhealthandthemajoremphasisonmentaldisorders(Seponski,etal.,2014).Whencomparedtotheemergingliteratureofpost-traumaticgrowthandpositivechange,thereisminimalconsiderationonsuchbenefitsasaresultofsufferinginCambodia(Zoellner&Maercker,2006).Therefore,moreresearchattentionneedstobegiveninthisareaofmentalhealthinCambodia.

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MentalHealth–LivedExperienceManystudieshaveattemptedtoexplainhowbothexternalfactorsandinternalfactorsareinterconnectedandinfluencelivingexperiences(Mollica,etal.,2014).Firstly,onestudyfoundthattherewasastrongcorrelationbetweenmentalhealthproblemsanddecreasedhealthandphysicalfunctioning(Mollica,etal.,2014).RespondentswhohadPTSDanddepressionexperiencedlethargyandfounddifficultyparticipatingindailyroutinesandactivities(Mollica,etal.,2014).Secondly,thestudyestablishedthefactthatpersonalandsocialfactorssuchasageandgenderiscorrelatedtopoormentalhealthoutcomesandindividuallivingexperiences(Mollica,etal.,2014).Specifically,femalesexperiencedahigherlevelofdepressionandPTSD(Mollica,etal.,2014).Thirdly,ongoingthreattosecuritywerefoundtoexacerbatementaldisordersandevery-dayliving(Mollica,etal.,2014).Theauthorhighlightedthattransitionfromatotalitarianregimeandconsolidatingademocraticgovernmentisalsoanongoingtraumaticexperience(Hein,2015;Zook,2010).However,thestudyconcludedthatdailystressorsweresubstantiallymorecriticalintriggeringadversepsychiatricreactionsandpsychologicaldistressthanhistoricaltrauma(Cantor-Graae,etal.,2014;Mollica,etal.,2014).

MentalHealth–CulturalConstructionHistoricallyandculturally,mentalhealthinCambodiahasoftenbeenminimizedanddenied(Hein,2015).Amajorreasonincludesthelackofknowledgeofmentalhealthandthesignificantstigmaaroundmentaldisorders(McLaughlin,2012;Schunert,etal.,2012).Hein(2015)foundthatstigmaisthelargestcontributortothesilence,fearandignorancewithincommunitiesregardingmentaldisorders.Additionally,theauthorlinksthecauseofthisperceptiontothelongtermpoliticallyagendatoportraymentaldisordersasinsanity(Hein,2015).

AnumberofauthorshavefoundthatCambodiansbelievethatthecauseandoriginofmentaldisordersismultidimensionalincludingreligious,spiritual,psychological,biologicalandphysical(Coton,Poly,Hoyois,Sophal,&Dubois,2008;Seponski,etal.,2014).Fromaspiritualperspective,Cambodiansbelievethatpsychologicalsymptomsaretheresultsofcurses,karma,witchcraftandancestralinfluences(Coton,etal.,2008;Seponski,etal.,2014).Psychologically,Khmerpeoplealsoassociateamentaldisordersasaresultofhavinga“weak”heart,overworking,toomuchthinking,orpossessingabrainornervedamage(Coton,etal.,2008;Seponski,etal.,2014).AstheKhmercultureseesthebodyandmindasaninterconnectedunit,havingadisabilityalsoconstitutestohavingaweakmind(Carter,2009;Gartrell&Hoban,2013;Vanleit,2008).Biologically,

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itisalsopossibletobelievethatamentaldisabilitystemmedfromheredity(Coton,etal.,2008).Ingeneral,peoplewithmentaldisordersareoftenregardedbyothereducatedmembersofsocietyasbeingunabletorecoverandrequiremedicaltreatment(Hein,2015).

MentalDisorders–CulturallyExperiencedMentaldisorderssuchasPTSDandpanicdisordersareculturallyexperiencedinCambodia(Hinton,Hinton,Um,Chea,&Sak,2002;Hinton,Um,&Ba,2001a,2001b;Hinton,Pich,Chhean,&Pollack,2005;Schunert,etal.,2012).Therearethreemajorsymptoms,whichhavebeenstudiedextensivelyandareacknowledgeasthelocalmanifestationofPTSDandpanicdisorders(Hinton,etal.,2002;Hinton,etal.,2001a,2001b;Hinton,etal.,2005;Schunert,etal.,2012).Specificallythisincludesthewindattack,thesleepparalysis(“ghostpushesyoudown”)andtheweakheartsyndrome(Hinton,etal.,2002;Hinton,etal.,2001a,2001b;Hinton,etal.,2005;Schunert,etal.,2012).Peoplewhoexperiencesuchsymptomsareseverelystigmatizedbythecommunityandpeoplewithschizophreniaareoftentreatedinhumanely(Hinton,etal.,2002;Hinton,etal.,2001a,2001b;Hinton,etal.,2005;Schunert,etal.,2012).Particularlyinruralareas,peoplewithschizophreniaexperiencecagingandchainingfrommonthstoyears(Schunert,etal.,2012).Asaresultofsignificantmacroinfluence,remainthemajorfactorsthatpreventpeoplefromaccessingcareinCambodia(Hein,2015;McLaughlin,2012;Schunert,etal.,2012;Seponski,etal.,2014).

MentalHealthServicesOverview

IntroductionMostpublishedresearchidentifiesthatmentalhealthservicesinmostlow-incomecountriessuchasCambodiainstitutionalize,pathologiespeoplewithmentaldisorders(HandicapInternational,2011;McLaughlin,2012;Schunert,etal.,2012).Specifically,thereareaccountsofviolence,torture,rape,sexualassault,forcedinjectionsandunsanitarylivingconditionsforthosewhoareinstitutionalized(McLaughlin,2012).Additionally,manyresearchurgesthatthistypeofmentalhealthserviceremainsinhumane,rudimentaryandunsustainable(HandicapInternational,2011;Schunert,etal.,2012).Literaturechallengestheneedformoreprimaryandacutepsychologicaltherapiesbutforincreaseinpromotingcommunity(Seponski,etal.,2014;Stockwell,etal.,2005).DespitesignificanteffortsfromNGOstodevelopmorecommunitybasedmentalhealthservices,thelackoffundingandeffectivecollaborationamongkeystakeholderscontinuetoprolongthisprocess(McLaughlin,2012;Schunert,etal.,2012).

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Almostallliteratureemphasizesthelimitednumberofpsychiatrists,psychologists,andmentalhealthworkersavailableinCambodia(Astbury&Walji,2014).Specifically,authorsestimatethatthereare350mentalhealthcareprovidersand35psychiatristsworkingin10differenthospitals(Seponski,etal.,2014;Stockwell,etal.,2005).Inotherwords,thereisonepsychiatristto530,000peopleinCambodia(Coton,etal.,2008).Apartfrompublicandprivatehospitals,communityservicesarescattered,undertrainedandalmostentirelyinaccessibletothoselivinginremoteandruralareas(Coton,etal.,2008;Seponski,etal.,2014).Despiteamajorfocusonmentaldisorders,onlyminimalprovisionshavebeenofferedtothosewhoareextremelyill(Coton,etal.,2008).Particularly,schizophreniaisoftencompletelypoorlyunderstoodandasaresultunderdetected(Coton,etal.,2008).Consequently,theoverwhelminglackofresearchonCambodia’smentalhealthpresentsamajorsetbacktowardspolicyimplementationandsustainablechange(Seponski,etal.,2014).Recentstudiessuggestthatthelackofevidencebasedpractice,limitedunderstandingofmentalhealth,poverty,naturaldisastersandwaralsorendermentalhealthservicesineffective(Seponski,etal.,2014).TheresearchfoundthatmanymentalhealthservicesinCambodiaareovertlyfocusedondiagnosingtreatmentandhistoricaltrauma(Seponski,etal.,2014).Authorsarguethatmoreattentionbutexaminespresentissues,environmentalfactorsandtheunderlyinghumanrightsissues(Gartrell&Hoban,2013;Seponski,etal.,2014).Thesespecificallyincludes,abjectpoverty,socialvulnerability,domesticviolence,corruptionandthelackofaccesstobasichumanrightssuchaspoornutritionandlimitedaccesstoeducationandhealthcare(Seponski,etal.,2014).Thelocationofthetherapywerealsoimportantaspectsthatrenderedmentalhealthservicesunsuccessful(Seponski,etal.,2014).Thelackofunderstandingtheshameassociatedwithobtainingmentalhealthserviceswasamajorsetbackinindividualsassessingservices(Seponski,etal.,2014).

Lastly,thefinancialsituationofmostpoorindividualswereamajorbarrierinobtainingeffectivementalhealthcare(Seponski,etal.,2014).Specifically,thelimitedfinancialresourceswereinsufficientforlongtermcarewhencomparedtootherpressingdailyfinancialneeds(Seponski,etal.,2014).Assuch,mostindividualsoftenaccessonlyalimitedamountofmentalhealththerapieswithoutanycontinuationoftheservice(Seponski,etal.,2014).

MultidimensionalHealthCareCambodiansengageinamultidimensionalhealthcareexperienceincludingbothWesternandtraditionalremedies(Somasundaram,etal.,1999).Specifictomentalhealth,CambodiansseekengagementinarangeofservicessuchasBuddhistspirituality,herbalhealingandWesternpsychology(Coton,etal.,2008;

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Mollica,etal.,2014).Studieshavefoundthattraditionalinterventionshavebeenfoundextremelyhelpfulforthosesufferingwithpsychologicaldistress(Somasundaram,etal.,1999).Awiderangeoffactorsspecifically,socio-economic,socio-cultural,socio-political,race,religion,familysupport,education,awarenessofservicesandtheinterpretationofdisordersallcontributetohealthcaredecisionmakingforCambodians(Coton,etal.,2008).

Priortoseekinghelpfromtraditionalhealers,Cambodiansengageinaseriesofremedialactivitiesincludingrecreation,Chineseherbalmedicines,alcohol,gamblingandsupportfromclosefamilyandfriends(Schunert,etal.,2012).Atthepointwhensymptomsdonotalleviate,Cambodianswillbeginseekinghelpfromtraditionalhealers,incantations,fortune-tellersandmonks(Coton,etal.,2008;Morgan&Tan,2011;Schunert,etal.,2012;Seponski,etal.,2014;Somasundaram,etal.,1999).Whensymptomsincreaseorarenotalleviated,ageneralpractitionermaybesoughttoprescribemedicationincludingChinesemedicinesaswellasWesternservices(Seponski,etal.,2014;Somasundaram,etal.,1999).Consequently,Cambodianswillhavespentasignificantamountofmoneyanduptotwodecadesofremedialandtraditionalhelp,priortoaccessingaWesternmentalhealthservice(Seponski,etal.,2014).However,itisimportanttoemphasizethatthescarcityofWesternmentalhealthservicesaswellasculturalnormsmajorlyshapethispatternofdecisionmaking(Coton,etal.,2008).

WesternService

Similarlytorehabilitationservices,mostmentalhealthservicesareledbyWesternNGOs(Schunert,etal.,2012).However,studieshavefoundthatmanyCambodiansdonotunderstandthedegreeofdifferencebetweenpsychologicalandpsychiatricneeds(Somasundaram,etal.,1999;Zook,2010).ResearchhasfoundthatmostCambodianshaveahighperceptionofWesternservicesaspredominantlydistributingprescriptivedrugs(Somasundaram,etal.,1999).ItisarguedthatthistypeofmentalhealthserviceareunsuitablefortherangeofpsychologicalneedsinCambodia(Somasundaram,etal.,1999).Asaresult,therehasbeenaninfluxofpsychologicalneedsintoacutementalhealthfacilities,whichhavecausedovercrowdingandanexhaustionofresources(Somasundaram,etal.,1999).Moreover,asacutepsychologicaltreatmentrequirelongtermfollowings,Cambodianswhomarefoundtoneglectfollowupappointmentsmaynotbenefitinthelongrun(Somasundaram,etal.,1999).Yet,authorshavefoundthatinordertomeettheexpectationofCambodiansforservice,mentalhealthprovidersoftenprescribeplaceboswhichhavefoundtobesomewhateffective(Somasundaram,etal.,1999).

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AuthorscautionthefocusonprovidingmoreWesternizedmentalhealthservices,asthiswouldunder-utilizeotherresourcesandexacerbatepoverty(Somasundaram,etal.,1999).Additionally,researchfoundthatmanymentalhealthserviceswereineffectiveduetothelackofculturalsensitivity(Seponski,etal.,2014).Statisticsshowthataround75%oftheservicesinmostdevelopingcountrieslacktheconsiderationofahumanrightsfocusandanunderstandingbetweenwhatconstitutestobecomingculturalappropriate(Mollica,etal.,2014;Schunert,etal.,2012;Seponski,etal.,2014).Inessence,servicesremainpowerimbalancedtowardstheexpert,unaccountabletothecommunity,insensitivetotheuniqueneedsofthecommunityandabsentoftheneedforadvocacyforaccess,gender,economicandsocialinequities(Seponski,etal.,2014).Asresult,mostauthorsclaimthatmuchofthementalhealthservicesinCambodiaremainirrelevantandineffective(Seponski,etal.,2014).

Yet,therearesomeevidencebased,Westernmentalhealthservicesthatpracticeswithaculturallyinclusiveframework(Seponski,etal.,2014).Recentevidencehasfoundthatculturalsensitivityrequiresadeeperunderstandingontheuniqueconstructionofeachcommunityspecificallyit’shistory,politicallandscape,culture,gender,socialandeconomicinequity(Seponski,etal.,2014).However,itisrecommendedthatanequalamountofcommunityservicesaswellasclinicalhospitalservicesbeprovidedinordertoeffectivelymeetthementalhealthneedsofCambodia(Schunert,etal.,2012).Thiscanincludetraditionalhealers,communityworkers,communitydevelopment,socialwork,publichealth,evidencebasedresearch,advocacyandpolicychange(Hein,2015;Mollica,etal.,2014;Somasundaram,etal.,1999).

DeterminantsofCare

Afewrecentstudiesfoundthatphysicalresults,knowledgeofmentalhealthandfacilitieswereinfluentialinthechoiceofcare(Coton,etal.,2008;Morgan&Tan,2011;Somasundaram,etal.,1999).Althoughaccessibilityandpovertyaremajorconstraints,distanceandfinancesweretheleastinfluentialaspectinchoosingthetypeofcare(Coton,etal.,2008).Lastly,educationwasfoundtobethemajorpredictorinchoosingWesternmedicine(Coton,etal.,2008).

OverviewBarriersBarriersarepivotalinunderstandingobstaclesandchallenges,whichshapethelivedexperiencesofpeoplewithdisabilities(Palmer,2011).Accordingtothesocialmodel,barriersallfallintothreeoverarchingbarriersincludingtheattitudinal,environmentandinstitutionalbarriersindicatedbytheWHO(Gartrell&Hoban,2013;WorldHealthOrganization,2011).Thesebarriersarea

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majorinfluencetothepsychosocialneedsofpeoplewithdisabilities(Vanleit,2008;Zook,2010).Anoverwhelmingthemeacrossallliteratureremainstobeenvironmentalbarrierssuchasaccessibilityandmobility(Zook,2010).Firstly,thedesignandconstructionofCambodianruralhomesaresignificantobstaclesforpeoplewithmovementrelatedimpairments(Vanleit,2008).Specifically,Cambodiandwellingsarebuiltonhighstillsandoftendoincludetoilets(Vanleit,2008).Moreover,ruggedsurfacesandmuddyfieldsareaconsiderablechallengeforthosewhohavewheelchairsandotherprosthetics(Vanleit,2008;Zook,2010).Majorhealthcarefacilitieslocatedinthecapitalcityareovercrowded,havenarrowdoors,multiplefloorsandinaccessiblebathrooms,makingaccessibilityforpeoplewithphysicalimpairmentsextremelydifficult(Vanleit,2008;Zook,2010).Attitudinalbarriersarealsoaconsiderableobstacleforpeoplewithdisabilities.AuthorshighlightthegovernmentsystemofCambodiaasbeinginfusedwithconflict,corruption,limitedinhumanresourcesandhaveminimalfunding(Seponski,etal.,2014).Asaresult,reformsforpeoplewithdisabilitiesremainalowpriority(Seponski,etal.,2014).Poorpolicyforpeoplewithdisabilitieslimitlifeactivitiesandfurtherinducessocialexclusion(HandicapInternational,2011).Consequently,peoplewithdisabilitiescontinuetoexperiencesignificantinequality,discriminationandstigma(Gartrell&Hoban,2013;Palmer,2011;Seponski,etal.,2014).Thesebarriersareamajorsourceofpsychologicaldistressforpeoplewithdisabilities(Gartrell,2010).

Poverty-DisabilityExtremepovertyhasaninterdependentandcyclicalrelationshiptopsychologicaldistress,mentaldisordersanddisability(Gartrell&Hoban,2013;McLaughlin,2012;Palmer,2011;Seponski,etal.,2014;WorldHealthOrganization,2011).Specifically,itisarguedthatpovertyperpetuatesdisabilityandthateradicationofpovertycannothappenwithoutincludingpeoplewithdisabilities(Carter,2009;Gartrell&Hoban,2013;Parnes,etal.,2009).Yet,itisarguedbyseveralauthorsthattheviewthatpovertyismonetaryremainsnarrow,oversimplifiedandrudimentary(Palmer,2011;Seponski,etal.,2014).Authorsarguethatpovertymustbeseenandunderstoodasabarriertocareonmultiplelevels(Palmer,2011;Seponski,etal.,2014).InCambodia,disabilityhasadirectandindirectimpactontheindividual,thefamilyandthecommunity(Durham&Hoy,2013).Specifically,peoplewithdisabilitiesandtheirfamiliesfacethelossofincome,productivityandassets,exhaustionofresourcesanddebtinordertomeettravelandburdensome

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medicalexpenses(Durham&Hoy,2013;Palmer,2011;Zimmer,2006).Moreover,membersofthefamilyarepreventedfromearninganincomingandotheractivitiesinordertobecomefulltimecarers(Cordier,2014).Thesemultidimensionalstrainsandtheinabilitytoaccumulatesavingsmajorlycontributetosignificantsocialisolation,poormentalhealthandlong-termintergenerationalpoverty(Durham&Hoy,2013;Palmer,2011).Palmer’s(2011)comprehensivecriticalliteratureonpovertyinmiddletolow-incomecountriesprovidesanextensiveinsightintothemultidimensionalpovertyandsocialdisadvantagefacedbypeoplewithdisabilitiesandtheirfamilies.Thefirstviewincludesthe“basicneedsapproach”whichconsidersdeprivationofbasicnecessitiesincludingfood,safety,cleandrinkingwater,sanitationfacilities,securehome,accesstoeducationandinformation(Palmer,2011;Seponski,etal.,2014).Morethan40%ofthepopulationinCambodialivesbelow$1.25USDadayandmedicalexpensesareaconsiderableburdenfamilieswithdisability(McLaughlin,2012).Specifically,peoplewithdisabilitiesandtheirfamiliesarerequiredtoredistributetheirincometowardsthesemedicalexpenses,whichprolongspre-existingpoverty(Cordier,2014;Gartrell&Hoban,2013).Secondly,the“capabilityapproach”examinesone’sabilityandtheircharacteristicsincludingage,genderandhealthstatustoconvertmeansandresourcesintowell-being(Palmer,2011).Particularly,peoplewithdisabilitieswhofacesignificantdiscriminationareoftennotabletoobtainincomeandcontributetotheirfamilies(Palmer,2011).Lastly,the“economicresourceapproach”examineswhetheranindividual’sincomeisbelowthepovertylineandtheirabilitytocoverthecostoftheirbasicneeds(Palmer,2011).Palmer(2011)highlightsthefactthatpeoplewithdisabilitiesinCambodiafaceallthreeapproachestopoverty.Asaresult,peoplewithdisabilitieslackthefundingtoengageincareandservicesthattheyrequire(Palmer,2011).

Peoplewithdisabilitiesalsoexperiencepoorsocialcapital(Palmer,2011).Socialcapitalincludesthevalueandbenefitsobtainedfromcommunityinteractionandsupport(Palmer,2011).However,asaresultofsocialdiscriminationandisolation,peoplewithdisabilitiesandtheirfamiliesarenotabletoleverageonsocialcapital(Palmer,2011).Asaresult,peoplewithdisabilitiesinCambodiaareconsideredthepoorestamongthepoorandthelargestandmostmarginalizedpeopleintheworld(Gartrell&Hoban,2013;Palmer,2011;Stockwell,etal.,2005).

Poverty–MentalHealthPovertyhasalsobeenfoundtoimpactonmentalhealth(McLaughlin,2012).Theextremelackofresourcescreatesanenvironmentconducivetopoorpsychiatrichealthduetoinsecurity,uncertaintyandvulnerability(Seponski,etal.,2014).

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Specifically,povertyinducesasociallyfrailpsychosocialenvironmentthatexacerbatesmentaldisorders(Parnes,etal.,2009;Seponski,etal.,2014).Afrailsocialenvironmentcanincludehavinglowerbirthrates,alackofimmunizationcoverage,ahighrateofaccesstoeducation,unemployment,underemploymentandpooraccessibility(Palmer,2011;Parnes,etal.,2009).Astudyfoundthatsignificantpovertyandindebtednessishighlycorrelatedtosuicide(Jegannathan,etal.,2015).Specificallythatwhenbasicneedsarenotbeingmet,mentalhealthcareremainalowlevelpriority(Seponski,etal.,2014).Itisclearthatpovertycreatesadisablingenvironmentofextremehardship,socialexclusionandpowerlessness(Palmer,2011;Seponski,etal.,2014).Therefore,centraltopolicychangeinCambodiaistheneedtoviewpovertywithamultidimensionalperspectiveandtoencourageandmoreintegratedservices(Palmer,2011;Seponski,etal.,2014).

3. Studymethodology

StudyObjectiveBasedonthebackgrounddescribedinthepreviouschapter,theaimoftheresearchistoanswerthefollowingquestions:

• Towhatextentispsychosocialwellbeingaffectedbyindividualandfamilyexperiencesofdisability?

• Whatarethecurrentpsychosocialcopingcapacities/strategiesofpeoplewithaphysicalormentaldisabilityandtheirfamilies?

• Toconsiderhowthepsychosocialwellbeingofpeoplewithdisabilitiescompareswithpeoplewithoutdisabilities.

• Toexplorewhatcurrentmentalhealthservicesexist?Arethoseservicesaccessible&inclusiveofpeoplewithdisabilities?

• Whatisthecommunityresponsetopeopleindividualswithphysicalandmentaldisabilities?

• Whoarethestakeholders,whataretheirapproachesandexperienceswithdealingwithpeoplewithdifferentimpairments,mentalhealthissues?IsthereanyinterestinpartneringwithHI&LD

• Whataretheexistingbarrierspeoplewithdisabilities&theirfamiliesfaceinaccessingpsychosocialhealthservices?

MixedMethodApproachThestudymethodologyincludedamixedmethodofquantitativeandqualitativeresearchusinganiterativeapproachtoensurethebestpossibleresearch

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outcomes.Theiterativeapproachusestheincrementalanalysisofeachstagetohelpbuild,refineandimproveprocessesandmethodologiesoftheupcomingphases.Thefive-stagedatacollectionprocessincludedacomprehensiveliteraturereview,focusgroupdiscussions(FGD),semi-structuredinterviewsandsurveys.Embeddedwithintheresearchdesignistheinclusiveprocesswhichensuresthatpeoplewithdisabilitiesaremeaningfullyandeffectivelyparticipatingineachprocess(HandicapInternational&FrenchAgencyforDevelopment,2015).Thedevelopmentofeachresearchtoolwasconductedinconjunctionwithapersonwithadisability,thelocalKhmerteam,LouvainCorporation,QueenslandUniversityofTechnologyandHandicapInternational.

SelectionandSamplingMethodsTheselectioncriteriaforparticipantsintheFGD,semistructurein-depthinterviewsandsurveysincludepurposivesamplingofpeoplewithdisabilitiesandtheirfamilies,communityleadersandvolunteersandkeyserviceproviderswithintheprovinceofKampongCham.Atotalof230participantswereselectedforthisresearchproject,whichincludedanequalamountofmaleandfemalesamongeachtargetgroup.AKhmerinterpreterwaspresentduringtheFGDandsemi-structuredin-depthinterviewsandavoicerecorderwasusedtocollectallthediscussionsParticipantswereexplainedabouttheresearchstudyandwererequiredtosignconsentformstoensurevoluntaryandfullparticipation.ExpectationsabouttheresearchwereexplainedtoparticipantsatthebeginningofeachsessionandallquestionspertainingtomentalhealthserviceswerereferredtotheappropriatestaffatthePRC.

QualitativeDataCollection

LiteratureReviewThefirststageincludedanindepthliteraturereviewofdisabilityandmentalhealthinCambodia.Atotalof60articleswerefoundwhichincludedgreyliteratureandpeerreviewjournalsfromacademicdatabases.TheresultsfromScopus,EBSCOhostandPubMeddatabasesusingthekeywords:“Khmer”,“Cambodia*”,“disability*”,“impairment”,“mental”,“psycho*”,“social”,“illness*”,“problem*”,“issue*”,“service*”,“care*”and“women”showed40relevantpeerreviewedarticles.Journalsfrom2000–2015werechosentoensureacontemporaryreviewofliterature.Itisimportanttonotethatoneseminalstudyfrom1999bySomasundaram,D.J.,vandePut,W.A.C.M.,Eisenbruch,M.,&deJong,J.T.V.Mwillusedinthisliteraturereview,todrawupontheonlystudyinCambodiaofpeoplewhohavebeenclinicaldiagnosedwithmentaldisorders.

FocusGroupDiscussions

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TheFGDwasselectedasamethodtodrawoutviews,optionsandthethoughtsofkeystakeholdersinashortperiodoftime.Thequestionsweredesignedinconjunctionwithacolleaguewithavisualimpairment,theKhmerteamandpartnerorganizationsinvolvedintheproject.Atotalof14FGDwereconductedwiththetotalnumberofparticipantsbeing112participantsinterview.Thegroupswererunwithmenandwomenwithdisabilitiesseparatelytoensurethatgenderspecificissuescouldberaised.Thefocusgroupdiscussionshadthefollowingselectioncriteria.Thespecificcriteriaforselectionincludedpeoplewithdisabilitiesincludedallages,anequalamountofmalesandfemalesacrossfourtypesofimpairments,thosewhodemonstratedsignsofpsychologicaldistressandacombinationofestablishedandnewbeneficiariesofthePhysicalRehabilitationCentre.Thesameselectioncriteriawereusedtoselectfamilymembers.TwogroupsofcommunitymemberswerechosenaccordingtocommunelocationbeingBohKhnourandSpeu.However,twogroupsofserviceproviderswerechosenaccordingtohealthcentersincludingChamkamLeuReferralHospitalandthePhysicalRehabilitationCentre.

TherewereatotalofeightFGDconductedamongpeoplewithphysicalimpairmentsfromthePhysicalRehabilitationCentre(PRC).Theselectioncriteriaincludedthosewhoaresuspectedofhavingpsychologicaldistress,psychosocialdisability,orpositivementalhealth.Theeightgroupsconsistsofthefollowing:

• 2groupsofpeoplewithadisabilitycausedbylandmineinjuries(maleandfemale)

• 2groupsofpeoplewhohasadisabilityduetoroadtrafficinjuries(maleandfemale)

• 2groupgroupsofpeoplewhohasacongenitaldisability(maleandfemale)

• 2groupsofpeoplewithaphysicaldisabilitycausedbydisease(maleandfemale)

TwoFGDwereconductedamongkeystakeholdersincludinghealthcenterstaff,referralhospitalstaff,PRCstaffandNGOworkers.Onegroupconsistsof,onemanager,oneheadofphysiotherapy,threesocialworkersandtwomobilizationofficers.ThesecondgroupconsistedofthreenursesfromChamkaLeuReferralHospitalandthreenursesandtwosocialworkersfromtheTransculturalPsychosocialOrganizationCambodia.TwoFGDswereconductedwithfamilymembersandcarersofthosewhohaveaphysicaldisabilityfromPRC.Lastly,twoFGDwasconductedwithmembersofthecommunityincludingcommunes,villagehealthvolunteersfromtwocommunities,BokKnorandSpeu.

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Semi-structuredin-depthinterviews

Therewere17in-depthinterviewsconductedintotalwiththefollowingkeystakeholders.

• 4stakeholdersincluding:

o 1representativeofProvincialHealthDepartment/TechnicalUnitinHealthPromotionatKampongCham

o 1OperationalDistricts/Supervisor/EvaluatorfortheHealthCentreandHospital

o 1ChiefofDisabledPeopleOrganization(DPO),KampongChamo 1ExecutiveDeputyofPoSVY

• 2stakeholders:o 1DoctorfromtheReferralHospitalKampongChamo 1HeadofPsychiatricUnitatKampongCham

• 5stakeholders:o Peoplewithaphysicalimpairmentwhodemonstratedsignificant

signsofpsychologicaldistress,psychosocialdisabilityandpositivementalhealth.

• 3stakeholders:o Familiesandcarersofthosewithaphysicalimpairmentwho

demonstratedsignificantsignsofpsychologicaldistress,psychosocialneeds.

• 3stakeholder:o Influentialcommunitymembers

QuantitativeDataCollection

SurveyThesurveycollectionconsistsof150participantswhohaveaphysicalimpairmentfromallcatchmentareasofthePRC.Thisnumberalsowouldconsistofanequalamountoffemaleandmaleparticipants.TwovolunteersrecruitedfromthePRCwerepeoplewithphysicalimpairments.Theresearcherandastaffmemberconductedatwo-daytrainingtoexplaintheresearchstudy,thesurveyandtopracticeusingthesurvey.

LimitationsoftheResearchAconsiderablelimitationtotheresearchincludesthefactthatalltheparticipantsinvolvedinthisresearchwererecipientsoftheservicesprovidedthroughthePhysicalRehabilitationCentre(PRC).Thefindingsshowthattheseservicesarefactorsthatcontributetopositivementalhealth.Specificservicescanincludephysiotherapy,socialworksupport,livelihoodsupportand

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counseling.Therefore,theresultsofthefindingsmaynotrepresentthatsituationfullyofthosewhohavenotaccessedPRCservices,howeveritcanbeconcludedthatforthosewhohavenotaccessedthePRCservicestheirsituationmaywellbeevenmorechallenging.

Thereweremajortimeconstraintsthatduringdatacollectionperiod.Asaresultofthis,livetranscriptionwasappliedinordertoprovidemoretimefordataanalysis.Additionally,duetothelackofhumanresources,backtranslationsofthetranscriptionswerenotaviableoption.However,extraclarificationwasmadeduringtheinterviewstoensureaclearerunderstandingofeachstatementorideathatwasverbalizedbytherespondents.Asaresultoftimeconstraints,theanalysisbetweentherelationshipofthemesandotherdemographicvariablesotherthangenderandtypeofimpairmentswerenotconducted.

Thereweresomelanguagebarriersasaresultofthelowlevelofeducationbyparticipantsandthelackofunderstandingofmentalhealth.However,considerableeffortshavebeenmadetoensureunderstandingandthattheKhmerinterpreterandtheresearchwoulddebrieftoensureanypointsthatwereunclear.TheKhmerinterpreterwasalsoapersonwithdisabilitiesandwasabletoprovideabetterunderstandingofthecontexttotheresearcherwhenrequired.

Oneoftheoriginalsurveycollectorstrainedbytheresearchhadtoreturntotheirhomeland.ThereforeareplacementcollectorwasassignedandtrainedbythefocalpersonbasedinKampongChamprovince.Anearlylimitationofthesurveycollectionwasthatparticipant’sagesbetween0-10wereselectedandfamilymembersandcarerscompletedthesurveysonbehalfoftheparticipant.

4.QuantitativeFindings

DemographicsAtotalof126surveyswerecollectedamongpeoplewithphysicalimpairmentsofbothgenders.Impairmentcause Female Male TotalCongenital 22 17 39(31%)Disease 11 24 35(28%)Landmines 13 19 32(25%)RoadTraffic 0 20 20(16%)TOTAL 46(37%) 80(63%) 126(100%)

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Part2:DisabilityThefirstquestionaimedtodiscoverhowpeoplewithdisabilitiesviewthemselves;theseweretheirresponsesinorderofthemostcommonanswerstoleast.Themajorityofrespondentsidentifiedthemselvesasbeingproud.Incontrast,peoplewithdisabilitiesalsosawthemselvesaspitiful.Whatisinterestinginthisdataistheextremecontrastbetweenfeelingproudandpitiful.Thethirdhighestviewamongpeoplewithdisabilitiesisnotbeingstrong.Onlythirdoftherespondentsidentifiedashavinglessrightscomparedtoothersinthesociety.ConceptofSelf TRUE

FEMALETRUEMALE FALSE

FEMALEFALSEMALE

Proud 100% 96% 0% 0.3%Pitiful 98% 100% 0.1% 0%Notbeingstrong

81% 81% 20% 19%

Ausefulmemberofthecommunity

67% 67% 33% 32%

Knowledgeable 61% 67,5% 39% 31%Amedicalcase 56% 41% 43% 59%Havingpoorhealth

52% 43% 48% 58%

Unabletodoanything

43% 46% 57% 54%

Havinglessrights

37% 36% 63% 64%

Part3:DefinitionofhappinessThetablebelowillustrateshowpeoplewithdisabilitiesdefinewhatitmeanstobehappy.Therespondentsvotedhygiene,havinggoodphysicalhealthandhavingmoney.Thefollowingtableshowsalltheaspectsencompassinghappinessamongpeoplewithdisabilitiesfromthehighesttolowest.Concept Female MaleHygiene 78% 74%Goodbody/physicalhealth

78% 70%

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Havingmoney 78% 73%Healthymind 59& 65%Sleepingwell 54% 55%Havingfriends 39% 55%Feelingsafe 23% 19%

Part4:GeneralfeelingsinlifeThetablebelowdescribesthegeneralfeelingsthatpeoplewithdisabilitiesexperienced.Onlyathirdoftherespondentsfeltworried,regret,upset,embarrassed,lonelyandangryallthetime.Mostpeoplewithdisabilitiesidentifiedfeelingregret,upsetandworriedfrequently.Additionally,theyfeltangry,upset,embarrassed,griefandlosssometimes.However,themajorityofrespondentsalsosaidtheydidnotfeelsuicidal,theneedforalcoholorfeltlikegivingup.Allthetime Female MaleWorried 26% 27%Regret 22% 19%Upset 15% 13%Embarrassed 13% 16%Lonely 9% 15%Devalued 7% 0%Grief/loss 4% 4%Overwhelmed 4% 4%Angry 2% 0%Crying/Givingup 2% 1%Frequently Female MaleRegret 50% 40%Upset 48% 39%Worried 43% 29%Angry 33% 20%Crying 29% 19%Embarrassed 26% 16%Griefandloss 24% 15%Overwhelmed 22% 13%Lonely 17% 12%Unabletosleep 13% 6%

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Dizziness 11% 6%Afraid/scared 9% 3%Devalued 7% 5%Givingup 2% 4%

Sometimes Female MaleCrying 60% 36%Angry 52% 58%Grief/loss 43% 49%Dizziness 40% 36%Embarrassed 33% 35%Upset 30% 48%Unabletosleep 28% 27%Afraid/Scared&Devalued

24% 29%

Worried 20% 31%Overwhelmed 20% 29%Lonely 17% 18%Needalcohol 4% 25%

Part4a:Confidencebeforeandafterimpairments.Thequestionsbelowwereusedtomeasurehowdisabilityimpactedonconfidence.Therespondentsidentifiedthattheyhavelossofconfidenceasaresultofdisability.Confidence Female Maleimpairment Sometimes SometimesAfterimpairment. Never Never

Part5:Depression,AnxietyandStressScore.DAS-21TheDepression,AnxietyandStressScores(DAS-21)wasasatooladoptedtomeasurethelevelofpsychologicaldistressforpeoplewithphysicalimpairments.However,asignificantamountofdatacouldnotbeusedasaresultofdiscrepancieswithinthedata.ToensureaccuracyintheDAS-21scores,only70resultswereusedincluding27femaleresponsesand44maleresponses.TheresultsbelowaremeasuredaccordingtotheDAS-21scales.

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Theresultsshowthatmenhadextremelyseverestresscomparedtowomen.However,womenstillshowedextremelyseveredepressionandsevereanxietyandstresslevels.Theseresultsconfirmthehypothesisthatpeoplewithdisabilitiesexperienceahighlevelofpsychologicaldistress.However,whethertheyexperienceahigherlevelofpsychologicaldistresscomparedtopeoplewithoutdisabilitiesrequiresfurtherdataofthepsychologicaldistressofpeoplewithoutdisabilities.FemaleScores Depression:16.76 Anxiety:7.80 Stress:30.527respondents ExtremelySevere Severe SevereMale Depression:14 Anxiety:6.9 Stress:30.544respondents ExtremelySevere Moderate ExtremelySevere

Part6:ImpactonlifeWhenaskedwhatwastheimpactonthelackofincomeintherespondentslife.Theparticipantsidentifiedthatthelackofincomeimpactedonfamily,accessingservicesandhinderedprogressinlife.Impactonlife Female MaleFamily 98% 96%Services 37% 39%Lackofprogressinlife 36% 33%

Part6.a:ImpactonsocialrelationshipsIntermsofsocialrelationships,respondentsidentifiedthattherewasnodifferenceinrelationshipbeforeandaftertheimpairment.Thisisrathersurprising,asthefocusgroupsandindividualinterviewsshowedisolationasafactorofconcern.Itishypothesizedthatthispartofthesurveywasnotunderstoodcorrectly,astheinstructionstofillinginthissectionmeansthattheremustbeconsiderableimpact.

Part6.b:TypesofdiscriminationWhenaskedaboutwhattypesofdiscriminationrespondentsexperienced,beingblamed,teasedandhavingbadwordsorswearwordsspokentoo,werethemostcommonexperiences.Theseexperienceswereidentifiedequallybybothgenders.

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Typesofdiscrimination Female MaleBeingblamed 65% 68%Beingteased 50% 54%Bad/swearwords 29% 24%

Part6.c:ImpactonexpectationsIntermsoftheimpactofdisabilityonexpectations,participantsidentifiedthattheirhopesformobility,workandmarriagewerethemostaffected.Thesinglemoststrikingobservationisthehighernumberoffemalesindicatingthattheexpectationformarriagewasmostlyaffected.Expectations Female MaleMobility 56% 65%Work 55% 66%Marriage 73% 52%

Part6.d:ImpactonfamilyParticipantsidentifiedthatthelargestimpactonthefamilyasaresultofdisabilityincludesneedingtobereliantontheirpartneranddiscriminationtowardsfamilymembers.Itisimportanttonotethatmoremalesindicatedbecomingmorereliantwhencomparedtofemales.Femalesexperiencedahighernumberofbeingcheatedupon,howevermenexperiencedmoredivorcefromfemalepartners.Impactonfamily Female MaleDepending/reliantonpartner

73% 81%

Discriminationtofamilymembers

50% 50%

Beingcheatedon 27% 4%Divorce 0% 25%

Part7:ServicesWhenaskedwhatserviceswerethemostandleastaccessed,exercise,freeserviceandphysiotherapywerethemostaccessedservice,thisislikelyduetorespondentsbeingPRCclients.Incontrast,materialneeds,livelihoodandbudgetforeducationweretheleastaccessedservice.

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Often Female MaleExercise 84% 87%Freeservice 84% 79%Physiotherapy 74% 62%Food&shelter 70% 70%Counseling 59% 55%

Never Female MaleMaterialneeds 93% 88%Livelihood 69% 69%Budgetforeducation 66% 82%Travelallowance 65% 63%

Part7a:ServicesthatcontributetopositivementalhealthThefollowingtableidentifiesthetypesofpositivementalhealthmechanismsthatarebeingused.Respondentsidentifiedthatencouragement,peersupport,havinggoodrelationshipsandsocializingwerethemostimportantpartofaccessingservices.Theyidentifiedtheseashelpfulinenhancingthesenseofwell-being.Aspectsthatcontributetofeelinggoodaboutlife

Female Male

Encouragementfromothers/peersupport

96% 99%

Goodrelationship 82% 73%Socializing 38% 25%Finance/earninganincome

29% 32%

Assistivedevices 18% 25%Awarenessagainstdiscrimination

16% 13%

Part7b:LocationofservicesAlmostallparticipantsidentifiedasbeinglocatedinKampongChamandaccessingservicesinthePRC.

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Part8:FutureServicesWhenaskedaboutwhatfutureservicestherespondentswouldlike,theyidentified10servicesasextremelyimportant.Theseinterestinglydon’tmatchwiththeservicestheyidentifiedthatcontributetopositivementalhealth,(see7a)VeryImportant Female MaleAssistivedevices 100% 100%Awarenessraisingoftherights/needsofpeoplewithdisabilities

100% 100%

Governmentsupportforpeoplewithdisabilities

100% 100%

NGOsupportforpeoplewithdisabilities

100% 100%

Assistancewitholdageing

100% 100%

Freehealthcare 100% 98%Counseling 98% 100%Mentalhealthservices 98% 97%Jobopportunity/employmentservices

85% 74%

GettingI.Dpoorcards 85% 78%

5.QualitativeFindings

Peoplewithphysicalimpairmentsandtheirfamilies

1. Theunderstandingofhealthandwell-beingwithintheKhmercontextThelargestconceptofhealthandwell-beingamongbothmenandwomenwithphysicaldisabilitiesandamongpeoplewithcongenitaldisabilitiesrevolvedaroundbeinghygienic.Participantsdescribedhavinggoodhygienesuchasaccessingcleanfoodandwater,havingacleanbodythroughtakingabathandwashinghands,andbeinginacleanenvironmentsuchasatidyandcleanhome.Alargerproportionofwomenwithdisabilitiesdescribehavingagoodandfunctioningbodyandhavingnobodilyillnesses,aswellbeing.

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Thesecondlargestconceptofhealthandwell-beingwasidentifiedbyparticipantsashavingincome.Themajorityofparticipantsexpressedthatincomewasassociatedwithbasicneedsandlivelihood.Asmallergroupofrespondentsidentifiedthatthelackofincomeasrelatedtoaccesstoeducation.Averylimitedamountofparticipantsidentifiedincomeaseffectingrelationshipswithrelativesandthewidercommunity.Asmallamountoffemaleswithdisabilitiesidentifiedthatsocializingwithotherindividualswithfamilieswithadisabilitieswasimportanttohealthandwell-being.

2. Howsadness,depression,distressanxiety(psychologicaldistress)affectpeoplewithphysicalimpairmentsandtheirfamilies?

a. LivelihoodIthasbeenidentifiedacrossallfocusgroupsthatlivelihoodwasthebiggestcontributortopsychologicaldistress.Specifically,incomewasmentionedasthelargestsourcetolivelihood.Mostparticipantsidentifythelackofwelfare/socialsupportandservicesprovidedbythegovernment.However,familiesandpeoplewithdisabilitiesoftenexpressthattheexpensesformedicaltreatment,travelexpensesandmedicationbecomeamajordrainageonincome,whichcontributestotheirpsychologicaldistress.Manyparticipantsalsoreportedthelossofassetsincludingthesellingofland,equipmentandvehiclesinordertomeetdailylivingexpenses.Theseparticipantsreportedsignificantpsychologicaldistressasaresultofthelossofassets.Somemaleparticipantsidentifiedthatthelackoflivelihoodaffectedtheirstatuswithinthecommunity,whichincreasedtheirpsychologicaldistress.

PscyhologicalDistressFamily

Livelihood

BasicNeeds&Shelter

Unemployment

ComparisonStigma&

Discrimination

Disability

Education

Community

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b. BasicNeeds&Shelter Thelackofbasicneedsisoftencorrelatedtodiminishinglivelihood.Almostallparticipantsexpresssignificantpsychologicaldistressasaresultofthelackoffoodduetotheinadequateincome.Someparticipantsexpressedsadnessthattheylivedinpoorerlivingconditionsasaresultofthedepletionofincome.Asmallamountofparticipantsidentifiedanxietyasaresultofthelackofsafetyintheirhomeandintheircommunityduetogangs.

c. Unemployment

Respondentsidentifiedthatunemploymentasaparamountcausetopsychologicaldistress.Participantsexplainedthatifthepartnerneedstobecomeacarerthenthereisdoublelossofincome.Specifically,respondentsdescribedtheneedtofindexternalassistance,whichmayincludeobtainingloansandsellingassetssuchasfarmlandsandmotorbikes.Peoplewithdisabilitiesandtheirfamilieshavedescribedfeelingsofintensestressfrombeingindebtandwhenaskedforrepaymentoftheirloans.Respondentsalsoidentifiedtheloosingofassetscontributedtolowself-esteemandalowsenseofstatusinthecommunity.

d. Family

Familywasequallyexpressedasamajorconcernforallgroups.Mostpeoplewithdisabilitiesidentifydependentsinthefamilysuchaschildren,partnersandageingparentsasasignificantsourceofconcern.However,participantsexpressedtoagreatdegreethattheresponsibilitytotakecareofoldageingparentscausesasubstantiallevelofpsychologicaldistress.

e. Comparison

Peoplewithdisabilitiesandtheirfamilieshaveidentifiedcomparisonasasourceofpsychologicaldistress.Foroneparticipant,thiswasidentifiedasamajorsourceofsuicideideation.Individualswithadisabilitywerecomparingthemselvesagainstotherfamilies,siblings,andotherpeople’schildrenwhoareabletoprogressinlife.Anexampleincludesonecareersayingthattheycouldn'twalk,hadtoselltheirmotorbikeandneverownedacarastheyhadhopedlikeeveryoneelse.Therewerealsomothersthatwouldcomparetheirchildtotheirotherchildrenandtheirfriend’schildren.Oneparticipantsaidthathiswifewouldlietoherworkcolleaguesregardingherhusbands’disabilityinordertosaveface.Thelackofhonorthatthepersonwithdisabilitybringsonthefamilywasidentifiedasasourcesadnessandpsychologicaldistress.

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f. StigmasandDiscriminationPeoplewithdisabilitiesandtheirfamiliesidentifiedstigmaanddiscriminationasamajorsourceofpsychologicaldistress.Participants,whohadacquiredimpairmentlaterinlife,experiencedahigherlevelofpsychologicaldistress.Participantscommonlydescriedthatneighborsbecomelessfriendlywhencomparedtobefore.InoneinstanceanEnglishteacherwasbelievedtobeunabletocontrolhisclassasaresultofarmimpairment.Additionally,theparticipantsalsoidentifiedthatthereisastrainanddistancingfromcloserelativeswhousedtoadmirehisadvice.Respondentsidentifiedthatthelackofvalueontheopinionsandviewsofpeoplewithdisabilitiesisolatestheminengaginginmeaningfulactivitiessuchascommunitydecisionsandconfinestheindividualintheirhomes.

g. Impairment

Theseverityofimpairmentwasamajordeterminantofthelevelofpsychologicaldistressassociatedtoeveryliving.Alargeamountofpeoplewithdisabilitiesandtheirfamiliesconsidereddailytasksasasourceofmajorpsychologicaldistress.Participantsexpressedthechallengesofruralofinfrastructureandsignificantenvironmentalbarriersespeciallywhenneedingtousethetoilet.Someparticipantshaveidentifiedthatdespitehavingprostheticstheenvironmentalbarriersstillmakelifeextremelydifficultforthem,especiallyonpoorlybuiltroads.Thelevelofdependenceorindependencewasalsoamajordeterminantforpsychologicaldistress.Forexample,asubstantialvolumeofparticipantsidentifiedthatbeinghighlydependentontheirpartnersforeverythingwasasourceofhighstressandsadness.Incontrast,participantswithassistivedevicesexpressedlesspsychologicaldistressasaresultoftheirabilitytobedependent.

h. Education

Peoplewithdisabilitiesidentifiedthatnotbeingabletoattendschoolwasasourceofhighpsychologicaldistress.Participantsdescribedenvironmentalandattitudinalbarrierssuchaslongdistance,inabilitytowalkintheraindespitehavingtheprostheticsandseverebullyingandname-callingasbeingassociatedtoeducation.Onecommunityhealthvolunteerrecountedthatsheknewonemaleadolescentwithadisabilitywhowantedtobuypoisonouspillstocommitsuicideasaresultofbeingunabletoattendschool.

i. Community

Thecommunityhasbeenidentifiedasamajorsourceofdiscrimination,socialexclusionandstigma,whichcontributestopsychologicaldistressforpeoplewithdisabilitiesandtheirfamilies.Peoplewithdisabilitiesandtheirfamilies

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describedexperiencesofteasing,blame,andswearwords,feelingsofdisgust,beinglookedat,mockingandharassmentbythecommunitymembers.Carersmayexperiencesignificantblameforthechildhavingadisability.Inonecase,theneighborstoldthemothersheshouldhaveletthedoctors’injectedmedicationtokillherdaughterasanewborninsteadoflettingherlive.Asaresultofsignificantdiscrimination,peoplewithdisabilitiesbecomeisolatedfromthecommunityandexperienceloneliness,whichfurtherexacerbatespsychologicaldistress.

FemaleswithphysicalimpairmentsAlmostallwomenidentifiedsadnessor“difficultinheart”asthemostcommonfeelingwithphysicalimpairmentsasaresultofthelackofincome.Alargemajorityofparticipantsidentifiedthereasonofsadnesstonotbeingabletodoanythingandexpressingadifferentlife.Somerespondentsexpressedsadnessasaresultoffeelingphysicallyweak,lossoflimbandlossoffriendsasaresult.Afewrespondentsexpressedfeelingsofembarrassmentduetohavingaweaklegandbeingdivorced.Asmallamountofparticipantsidentifiedfeelingnervousasaresultoftheirinabilitytomakeanincome,difficultinwearingshoesanddiscriminationandbullyingatschool.Onlyoneparticipantsaidthattheywereangrybecausethecommunityhadencouragedherhusbandtodivorceherasaresultofthedisability.Familywasidentifiedbeingdirectlyimpactedasaresultofpsychologicaldistress.Psychologicaldistressmadedecision-makingandconflictresolutionwithothersandfamilymembersmoredifficultastheywereconstantlyannoyed,wereimpatientandstressed.Conflictinthefamilycanincludesayingbadwordstoeachother,clashingwithoneanotherandfeelingconstantanger.Intermsofsociallife,femalerespondentsexpressedfeelingalackofinterest,beingunabletosocializeandfeelingisolatedandembarrassed.Thereweregeneralsymptomsthatweredescribedbywomenwithphysicalimpairmentsincludinghavingsevereheadaches,dizziness,anxiety,bodyachesandashakingheart.Someparticipantsidentifiedthattheyhadtotakemedicationandintravenoustherapytolessentheseverityoftheheadachesandothershadcontemplatedsuicide.Onlyafewmentionedthattheyweresadbecausetheystayedathome,livedalone,hadpoorbalanceandwereunabletodemandforbetterlivingconditions.Amongfemaleparticipants,whohaveidentifiedthatpsychologicaldistressimpactedtheirdailylife,specificexamplesincludedtheinabilitytoconcentrateindailyactivitiessuchasworkandstudies,tothinkofnewideasandenergylevels.

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Someparticipantsexplainedfeelingundesirableandunsuitableformarriagewasasignificantsourceofsadness.Oneparticipantaskedherhusbandtodivorceher,asshewantedtoprotecthimfromembarrassment.Anotherparticipantsaidthatherneighborsurgedherhusbandtodivorceherduetothedisability.Somewomensharedthattheyweredivorcedoncetheyobtainedimpairment.

Maleswithphysicalimpairments

Maleswithadisabilitydescribedasignificantamountofpsychologicaldistressasaresultofthewifeneedingtobecomethebreadwinnerandsolesupportforthefamily.Specificallythisincludesnotbeingabletoprovideforthechildren’seducation.Whenaskedwhatpsychologicaldistressdidthemaleswithphysicalimpairmentsfelt,theparticipantsdescribedfeelinghopeless,stressed,anxious,scared,andasenseofgriefandloss.

Asecondmajorreasonfortheirpsychologicaldistresswasidentifiedaspoverty.Specifically,participantsassociatepovertytopoorlivingconditions,havingpoorparents,havinglowsalaryandnofood.Otherreasonsthatcontributedtopsychologicaldistressincludeavarietyofreasonsincludingthedisability,discriminationandbeingunabletocontributetothewell-beingandneedsofthefamily.

Maleparticipantswhohadroadtrafficaccidentsfrequentlyexpressedthattheyfeltscaredevery-dayandwereeasilytraumatized.Specificallytheyexpressedfeelingscaredofbeinginacar,beingonsomeone’sbackorridingonthebackofthemotorbike.Thesesymptomsmaysuggestsignsofposttraumaticstressdisorder.

Menwithcongenitaldisabilitydemonstratedhighlevelsofpsychologicaldistressthatmayleadtoapsychosocialdisability.Menwithcongenitaldisabilitiesexpressverylittlemotivationduringtheinterviewsandhaveidentifiednosourceofpositivementalhealth.Oneparticipantdescribedfeelingdisempoweredtoremovehispsychologicaldistress.Theparticipantmentionedthattheyhaveideasbutareunabletoactuponthem.Someparticipantsfeltdisempoweredtowalkoutsidetheirhomesandfeltlikethattheyhadnomorefuture.Amongmenwithcongenitaldisabilitiesverylittlepositivementalhealthwasidentified.Theonlysupportidentifiedincludedhavingrelationships,socializing,havingpurpose,andbeingempoweredandreceivingassistivedevices.Thereislittlerecognitionofmentalhealthissuesoranysolutiontosymptomstomentalhealthissues.

FamiliesandCarers

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Almostallcarersexpressedthesignificanthardshipanddutiesrelatedtocaringforapersonwithadisabilityasamajorsourceofsadnessanddistress.Thesecarersoftenhighlightthelackoffamilysupport,governmentsupportandpoorlivingconditionstheylivein.Additionally,alargemajorityofcarersreportedthattheylackedincometoprovideforthemselves,thepersonwithadisabilityandotherdependentsinthefamilyandfeltanxiousaboutthefuture.Manycarersoftenselltheirassetsandquittheirjobsinordertobecomefulltimecarers.Somecarersexpressedthattheybecameisolatedasaresultofneedingtobecomeafulltimecarerandthismadethemfeellonelyandsad.

Somecarersidentifythatphysicalviolenceandemotionalabusefromthepeoplewithdisabilitiesofwhomtheyarecaringfor,wasamajorsourceofpsychologicaldistress.Respondentsdescribedbeingblamedbythepersonwithadisability,complainingandanger.Motherswhoareoftencarersmentionedpsychologicaldistressasaresultofthediscriminationandbullyingthechildrenwithdisabilitiesfaceatschool.Afewcarersmentionedthattheyhadlowerself-esteemandfeltembarrassedasaresultoftheirchildwhohasadisability.

Aconsiderableamountofcarer’salsodescribedexperiencesofdiscriminationasaresultofthechildwithadisability.Forexample,onerespondentexplainedthatshewasblamedforherlackofeducationduringpregnancy,whichhasresultedinthechildobtainingacongenitaldisability.Significantpsychologicaldistressexperiencedbythecarermayproduceconsequencessuchasblamingthepersonwithadisability,wantingtoleavethechildwithdisabilitybehind,becomingphysicallyviolentsuchasthrowingthings,wantingtorunawayandbecomingemotionallyviolentandraisingone’svoiceorshouting.

3. Thepositivementalhealth(optimism,self-esteem)ofpeoplewithphysicalimpairmentsandtheirfamilies

ThePhysicalRehabilitationCentre(PRC)hasbeenidentifiedasthemostdominantsourceofpositivementalhealthamongallpeoplewithdisabilitiesandtheirfamilies.ParticipantshaveidentifiedthatthePRCprovidedthemwithdirectemotionalandtangiblesupport.Respondentsgavesimilarexamplesincludingcounseling,rehabilitation,assistivedevices,adviceonhowtoliveinsociety,budgetforeducation,shelter,food,financialassistance,materialgoodsandphysiotherapy.Thesecondlargestsourceofpositivementalhealthwasdirectlytoregainingabilitytoperformbasictasks.Thisisoftendescribedbyparticipantsasbeingabletoengageindailyactivitiessuchaswalking,working,bringingwater,cookinganddoingwhatevertheywant.Carersandfamilymembersalsoacknowledgedthatseeingpeoplewithdisabilitiesgainmobilitywasasourceof

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theirjoyandprovidedasenseofhopeforthem.Thethirdsourceofinformalpsychologicalsupportidentifiedbyallparticipantsisencouragement.Mostparticipantsidentifiedthatencouragementcamefromfamilymembers,thecommunityandthestaffatthePRC.Lastly,bothpeoplewithdisabilitiesandcarersidentifiedthatkeepingbusyandentertainedprovidedrelaxationandrelieffrompsychologicaldistress.Theseincludedwatchingtelevision,goingtoascenicplace,meetingfriends,andsingingashelpful.

FemaleswithphysicalimpairmentsThelargestaspecttohappinessforwomenwithdisabilitieswasobtainingassistivedevicesthatallowedthemtobeactiveandmobile.Theactivitiesidentifiedincludedbeingabletowork,carrywater,cook,driveamotorbike,gotothemarket,washclothes,cleanthedishesandcleanthehouse.Asmalleramountofwomenexpressedthatbeingabletojointraditionalevents,beingindependentandseeingotherswithsimilarproblemscontributedtofeelingsofhappiness.Whenaskedaboutwhatcontributedtopositivementalhealth,femaleswithphysicalimpairmentsidentifiedthatencouragementandhavingworkwerethetwoimportantaspects.However,forfamiliesandcarersitwasseeingthechildorpersonwithdisabilitiesgetbetter.Religion,beingactiveandgainingabilitywasidentifiedassomewhatsignificantfactorstopositivementalhealth.

Maleswithphysicalimpairments

Incontrasttofemales,incomewasamajorcontributortopositivementalhealthformaleswithphysicalimpairments.Itwascleareramongmaleswithlandmineinjuriesthatprogresswasanimportantaspectofpositivementalhealth.Otherreasonsthathelpedpositivityincludedhavingaskill,beingabletosupportparents,socializing,religionandhavingself-confidence.

4. Toidentifyhowpsychologicaldistressandpositivementalhealthaffectbarriersandfacilitatorstoservices.

Noparticipantsidentifiedthatpsychologicaldistress(sadness,anxietyordistress)deterredthemfromengagementinservices.However,positivementalhealthplayedagreaterroleinfacilitatingservices.Allgroupsidentifiedregainingmobilityasamajorencouragementtoreturntoservice.Alargenumberofpeoplewithdisabilitiesandfamilymembersexpressedthattheywerewillingtoovercomeobstaclesinordertomeetwiththesupportivestaffandotherswhosharedsimilarexperiences.

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Community

5. Thecommunityunderstandingofpsychologicaldistressandpositivementalhealth

Whenaskedwhatpsychologicaldistress(sadness,anxietyordistress)meant,thecommunityassociatedpsychologicaldistressmainlytochronicdisease,poorlivingstandardsandpoverty.Poorlivingstandardsincludedalackofshelterandfood.However,povertywasconsideredaslivinginpoorconditionsandowingmoneytopeople.Otherreasonsweregiventoexplainpsychologicaldistresssuchasnothavingawayforward,unemployment,andlackofeducation,havingtoomanychildren,comparedtoothersandhavingnoonetodependon.Afewparticipantsexpressedthatthinkingalotandbeingunabletosleepcontributedtopsychologicaldistress.Onerespondentmentionedthatlackofintellectispsychologicaldistress.Thecommunityidentifiedthatpeoplewithdisabilitiesandtheirfamiliesexperienceanxiety,sadnessandsuicideideationrespectively.Participantassociatedanxietytothelackofability,loweducation,lackofincomeandunemployment.Sadnesswasattributedtodivorce,discriminationandpoorhygiene.However,suicideideationwasdescribedwhensadnessandanxietyisexacerbatedbydiscriminationsuchbullyingandharassment.Thecommunityidentifiedcounselingasasourceofpositivementalhealth.However,doinggood,givingdonations,workingandreceivingreferraltomentalhealthserviceswerealsocommonthemesaroundpositivementalhealth.Feweractivitieswereoutlinedascontributingtopositivementalhealthincludingmedicine,activities,andgoingtothedoctorhelpfulforpositivementalhealth.

6. Whatisthecommunityresponsetopeoplewithphysicalimpairments?Themainconceptofdisabilityamongthecommunityrevolvesaroundthenotionofpity.Additionally,communitymembersidentifythatwithpeoplewithdisabilitiestheyarealwaysinlackandrequirehelp.However,communityleaders,keyvolunteersandmembersareawarethatpeoplewithdisabilitiesfaceandtheirfamiliesfacesignificantdiscriminationandarevulnerablemembersofsociety.Specifically,mostcommunechiefsrecognizedthatpeoplewithdisabilitiesandtheirfamiliesareostracizedandrejectedwithinthecommunity.Thecommunitychiefsidentifiedthattheyhavemadeeffortstopromotetherightsofpeoplewithdisabilities,fundraisefromNGOs,reducepovertyandhelpmaketheirlivesbetter.Additionally,acommunityleadermentionedthatheinformshisteamtopayattention,notignoreandtreatpeoplewithdisabilitiesandtheirfamiliesequally.

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Fromconductingtheinterviewsmostcommunitymembersandserviceprovidersadmitthatthereisalackofrecognition,lackofconfidenceinabilityandskills,apoorexpectationofworkperformanceanddisbeliefinworkcapacityofpeoplewithdisabilities.Despitepromotingpeoplewithdisabilitiestoworkhard,thereisaseverelimitationofappropriatejobopportunitiesforpeoplewithdisabilitiesortheirfamilymemberswhoarefulltimecarers.Forexample,onecarerhadtoworkirregularlytoassistthechildtogettreatmentbutwasfiredandblamedforherinconsistentworkschedule.Forcarersandpeoplewithdisabilities,theyexpressfeelinghopelessandextremelystressedasaresultofinflexiblejobopportunities.

7. Theroleofthecommunityineffectingbarriersandfacilitatorstoservices.

Thecommunityhasidentifiedthattheyprovideasignificantlevelofinformalsupportsuchasencouragement,informationdistributionandcharitabledeeds.Theyhavedescribedtheirrolesasprovidingitemslikenoodles,rice,somebudgetandsomechickens.Thecommunityvolunteerswereidentifiedasplayingamajorroleinraisingawarenessanddistributinggeneralinformationaboutpublichealth,basicmentalhealth,socialservicesanddomesticviolence.Onevolunteerinthecommunityexpressedthatthereisalackofavailablehumanresourceswithinthecommunitytomeetalltheneedsofthefamilywithchildrenwithdisabilities.Onsomeoccasionsthecommunityleadersandvolunteersencourageothervillagerstohelpsupportpeoplewithdisabilitiesandtheirfamilieswithmaterialgoods.

Thecommunityvolunteersidentifiedsignificantabuseforpeoplewithseveredisabilitiesandmaybetheonlysourceofdetection.Specificallycommunityvolunteerswereabletoidentifythatwhenthepeoplewithdisabilitieshavegrownolder,familiesandpeoplemoveonandthereislesscareandattentiontowardsthem.Acommunityvolunteergaveanexampleofparentsthatwererequiredtoearnanincome,wholeftthepersonwithadisabilityalonewithoutanymealinthehouseuntiltheirreturn.Althoughthecommunityvolunteeraskedthefamiliestotakecareofthepersonwithadisabilitytherewasnoactionimplementedandtheadvicewasignored.Incontrasttherearealsocasesofchildrenwhowereneglectingtheparentwithadisability.

ServiceProviders&Stakeholders

8. Thestakeholdersunderstandingofpsychologicaldistressandpositivementalhealth

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Thegeneralviewofthestakeholderstowardspeoplewithdisabilitiesispity,theinabilitytowork,lackingeducationandhavepoorlivingconditions.However,thedegreeofknowledgeregardingthechallengesandthelevelofpsychologicaldistressesthatpeoplewithdisabilitiesandtheirfamiliesfacevarysignificantlybetweenserviceproviders.Ingeneral,serviceprovidersfelttheywereabletoaddressgeneralmacroproblemsthatcausementalhealthissuesincludingtheissuesofpoverty,lackingfood,poorshelter,genderinequality,pooragriculture,notowningland,domesticviolence,discriminationandalcoholism.Additionally,serviceproviderswereabletoequatetheseissuestothelackofgovernmentinfluence,lackofhumanresources,lackofresourcesandthelackofresearchregardingthedisabilitysectorwithinCambodia.Almostallserviceprovidersacknowledgethatpeoplewithdisabilitiesandtheirfamiliesfacesubstantialattitudinalbarrierswithinthecommunity.

Mentalhealthserviceprovidersstatedtheywereabletoaddresssignificantproblemsamongthegeneralpopulationsuchasdepression,suicideideation,sleepingproblemsandpsychosisbuthadverylittlecontactwithpeoplewithdisabilities.Almostallserviceprovidersidentifiedthatdiscriminationbyfamilyrelationshipswouldoftenhaveaneffectonpsychologicaldistress.Whenaskedaboutstrategiesforpositivementalhealth,mostserviceproviderssaidtheyofferedfriendlyservices,encouragingpeoplewithdisabilitiestoavoiddepression,geteducatedandthat“onedaythey’llgethonoredforsucceedinginlife”.

Serviceproviderswhoareinhighpositionsheldastrongmedicalview,heldcommonstereotypesandhadlittleunderstandingaboutthepsychologicaldistressofpeoplewithdisabilitiesandtheirfamilies.Thisgroupdescribedpeoplewithdisabilitiesaslackingcapacity,lackingtheabilitytoachieveandlacktheabilitytothink,aremostlybeggars,don’thaveafutureandexperiencediscrimination.Yet,therespondentsinhighpositionsadmittedthattheylackknowledgeanddirectexperiencewhenworkingwithpeoplewithdisabilities.Specifically,theyoftenexplainedthatthefrontlineworkersweretrainedbutthisinformationisnottransferredthroughtoleadershippositions.Theyalsoexplainedthatthedemandontheirrolewithinaresourcepoorenvironmenthasnotallowedthemtheavailabilitytojointhesetrainingevents.Asaresult,mostprojectsandpolicieslacktheconsiderationofpeoplewithdisabilities.Onecommentbythisgroupwasmadethataspeoplewithdisabilitiesarelessproductivethereforetheyarelessvaluable.Anothercommentwasthatpeoplewithdisabilitiesbecometheresponsibilityofneighborsandpagodas.Serviceprovidersinmiddlemanagementweremoreawareofthemacro,mezzoandmicrochallengesthatpeoplewithdisabilitiesfacewhichconstitutestopsychologicaldisorders.Theyidentifieddifficultyinfindingemployment,

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struggletoperformwork,lackopportunityandlackincome.Theywerealsoabletorelatethesefactorstopoorqualityoflife,impactsonmarriage,familyconflict,discrimination,bringingdishonortothefamilyanddomesticviolence.Additionally,aserviceproviderexpressedthatparentswilloftenencouragetheirchildrentodivorcetheirpartnerwithadisability.Someserviceprovidersmentionedthatfamilieswouldhidepeoplewithdisabilitiesandthosewhoweremarriedtoapersonwithadisabilityhadnofuture.

TheheadoftheDisabledPeople’sOrganization(DPO)providedconsiderableinsightonthepsychologicaldistressofpeoplewithdisabilities.Specifically,thatpeoplewithdisabilitiesexperiencehighlevelsofstressandangerasaresultofdiscriminationandunemployment.Additionally,therespondentidentifiedacomprehensiveviewofdisabilityandothercomplexbarriersincludingthepsychologicaldistresscausedbypubertyamongyoungpeoplewithdisabilities,thelackofinclusiveeducationandhighlevelofsexualabuseanddiscriminationamongwomenwithdisabilities.

9. Towhatextentdoespsychologicaldistressandpositivementalhealthaffectbarriersandfacilitatorstoservicesforpeoplewithphysicalimpairmentsandtheirfamilies?

Serviceprovidersexperiencesignificantfrustrationwhenprovidingservicesforpeoplewithdisabilities.Theyidentifiedexperiencingabuseandfrustrationforthepersonwithadisability.Aswellasthistheystatedfamilymemberswouldattendappointmentsinsteadofthepersonwithadisability.Asaresultofthis,serviceproviderswerenotabletodiagnosetheillnessandthefamilyhadincurredlossduetotravelexpensestothehospital.Thosewhohadexperienceworkingwithpeoplewithdisabilitiesdescribedthattheclientswereangry,annoyedandimpatientquickly.However,theyalsomentionedthatpeoplewithdisabilitiesexperiencesignificantopportunitylossasaresultoftravellingandarerequiredtowaitalldaytobeseenforappointments.Someprovidersofferextramedicationtohelppeoplewithdisabilitiesandtheirfamiliesavoidtravellingmultipletimestoservices.Traditionalhealerswereidentifiedasasourceofpsychologicaldistressastheydrainfinancesonpeoplewithdisabilitiesandincurfurtherpsychologicaldistress.Somefieldinterviewsrevealedthatgiventhepreconceptionsrelatedtomentalhealthissuesatthecommunitylevel,visitingtraditionalhealerscouldalsohelppeopletobebetteracceptedinthecommunityastheyhavetriedtocurethemselvesfollowingthetraditionalway.Somepeoplewithdisabilitiesobtaindebttopayfortraditionalhealers,whichcausesfurtherpsychologicaldistress.

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Whoarethestakeholders,whataretheirapproachesandexperienceswithdealingwithpeoplewithphysicalimpairments?

Serviceprovidersandcommunityleadershaveidentifiedthatadvocacyandpromotinginternationaleventsthatemphasizetherightsofpeoplewithdisabilitiesiscritical.Raisingawarenessaboutlivedexperiencesofpeoplewithdisabilitiestohigh-rankingofficialsandinstitutionssuchashospitals,thegovernmentandtheprivatesectorisessential.

Serviceprovidersandcommunityleadersalsoidentifiedlegalassistanceforpeoplewithdisabilitiesasparamountwhendealingwithpeoplewithdisabilitiesandtheirfamilies.Someserviceprovidersacknowledgethatthereisverylittleimplementationofdisabilitylawandalackoflawtoprotectpeoplewithdisabilities.Participantsidentifiedthatpeoplewithdisabilitiesandtheirfamiliesrequireassistancewhentheyfaceaccidents,domesticviolence,abuseandotherlegalneeds.Specifically,thechiefrecommendedthateducationandwarningtofamiliesaboutpunishmentiftheyabusepeoplewithdisabilitieswouldhelpreducetheviolencethathappensinfamilies.Educationforfamiliesaffectedbydisabilityincludeshowtohaveresilienceandavoidabusetowardspeoplewithdisabilities.Additionally,thecommunitychiefalsomentionedthathewouldpointpeoplewithdisabilitiestoauthorityiftheyhaveneedsregardingpeopleandavoidbecomingfrustrated.Thecommunitychiefsaidthatoncetheneedhasbeenidentifiedsuchasneedingajob,theywouldcontactorliaisewithNGOstohelpfindthemajob.However,serviceprovidersalsoacknowledgethatthelackofbudgetandhumanresourceisamajorbarriertoimplementinglegalassistanceforpeoplewithdisabilities.

Trainingofothergovernmentsectorsthatarenotdisabilityrelatedwasidentifiedasanimportantstrategytoincreasetherightsofpeoplewithdisabilities.However,thecommunityandserviceprovidersregardedNGOsasthemainsourceforeducatinggovernmentsectorsandprovidingawarenessontherightsforpeoplewithdisabilities.Additionally,NGOswerealsoregardedasthemainsourceofsupportandavenueforemploymentforpeoplewithdisabilities.Ithasbeenidentifiedthatcommunityleadersandvolunteersactivelypromotethesehopestopeoplewithdisabilitiesthat“oneday”anNGOmayprovidefreeeducationandajob.Additionally,high-levelofficialsidentifiedthattheyshouldbeinvolvedtrainingandworkshoprunbyNGOs.However,serviceprovidersmentionedthatinternationalNGOsshouldhelpeducateandraiseawarenessaboutpoliciesandresearchforpeoplewithdisabilities.Onlyafewserviceprovidersmentionedtheneedforfurthermentalhealtheducationandtraining.

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a. Thecurrentmentalhealthservicesexisting,arethoseservicesaccessible&inclusiveofpeoplewithphysicalimpairments?

Serviceprovidershaveidentifiedthattherearementalhealthservicesavailableatthehospitalandhealthcenters.However,serviceprovidersdescribedthattheyhavehadverylittleexposuretopeoplewithdisabilitiesandtheirfamilies.Serviceprovidersidentifiedthatraisingawarenessregardingmentalhealththroughradioandposterareineffectiveandhomevisitsarethepreferredwayoftransferringknowledge.Additionally,serviceprovidersexplainedthattheindividualswithdisabilitiesandtheirfamiliesthathadlow-leveleducationsrequiredengagementwiththeinformationinorderfortheinformationtobeeffectivelyreceived.Intermsofaccessibility,someserviceproviderswereabletoidentifytheimportanceofcarer’sinaccessinghealthcare,theneedformoreawarenesswithinthecommunityregardinghealthservicesandthedifficultiesoftravellingtoservicesforpeoplewithdisabilities.

b. Whataretheexistingbarrierspeoplewithphysicalimpairmentsandtheirfamiliesfaceinaccessingservicese.g.physical,attitudes,practices,policies?

i. LackofKnowledgePeoplewithdisabilitiesandtheirfamiliesexperienceservicesthatlackappropriatedesignandsensitivityoftheirneedsandlivedexperiences.Frontlineserviceprovidersatthehealthcentersdescribedthelackofaccessiblebuildingfacilities,thelackofappropriateprocessesforpeoplewithdifferenttypesofimpairmentsatthehospital(i.e.peoplewhohaveavisualimpairmentorhardofhearing)andlackoftoiletfacilitiesforpeoplewithdisabilitiesatthehospital.Respondentsinhighpositionsadmittedthattheyhavehadnocontactwithpeoplewithdisabilitiesandlackedtheknowledgeoftheirneeds.Theymentionedthatmanyfrontlineworkerswouldreceivetrainingbutknowledgeisnottransfertotheirlevel.Additionally,high-rankingofficialsidentifiedthatpeoplewithdisabilitieshavenotbeenincludedandconsideredinthedesignofservices.Asaresult,peoplewithdisabilitiesexperiencesignificantadversitywhenusingpublicservices.

Serviceprovidersalsoexplainedthattheydonothaveaclearunderstandingofthespecificneedsofpeoplewithdisabilitiesincludingtheprevalenceratesofimpairmentintheircommunity.Thespecificinformationthattheyidentifiedtobeusefulincludedthenumberofpeoplewhorequirededucation,thenumberofmaleversusfemaleindividualswithdisabilities,thosewhorequiredfinancialassistanceandthosewhoneededassistancewithemployment.Onecomment

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madewasthatpeoplewithdisabilitiesdon’texperiencebarriersandchallengeswhenaccessingservices.Asaresult,servicesforpeoplewithdisabilitiesremaininconsistentamonggovernmentservicesandNGOs.

ii. LackofResources

Peoplewithdisabilitiesandtheirfamiliesdonotreceiveaccesstogovernmentassistanceandprogramsasaresultofpoorimplementation.Specifically,thelackofhumanresourcesandbudgetswerethemajorsourceoftheirinabilitytoactionoutthesepoliciesfromthegovernment.Aserviceprovideridentifiedexpressedthatdespitenewlawsbeingenforcedbythegovernmentondisability,therehasbeenverybeenalimitedamountofimplementationofthoselaws.Specifically,acharityboxandacommitteewereformedforpeoplewithdisabilitiesasaresultoflegalrequirementsbuttheseprogramshavenotbeenimplemented.Someserviceprovidersascertainedthatthecommunityalsolackedthenecessaryresourcestoeffectivelyhelppeoplewithdisabilitiesandtheirfamiliesandthisrolebelongedtothegovernment.TheyhavealsoindicatedtheymanyNGOsdonotadheretotherightsofpeoplewithdisabilitiesandwerenotabletooperatepracticallyaccordingtopolicies.

iii. CharityFocusedMostserviceprovidersseepeoplewithdisabilitiesasrecipientsofcharity.However,thisviewisenforcedastheyexpressedthatpeoplewithdisabilitiesandtheirfamilyoftenrequestformonetaryassistance.Despitethisview,manyserviceprovidersacknowledgethistypeofassistanceasunsustainable.

DiscussiononadditionalfindingsandconclusionsAsaresultofrichdataobtainedfromtheresearch,thesethemeshaveemergedthatfalloutsidethescopeofthisresearch.However,thisinformationprovidesadditionaldepthandinsightintothecurrentdiscussionsaroundmentalhealthissuesfacedbypeoplewithdisabilities.Theadditionaldiscussionswilladdressmajorthemesthathaveemergedwithinthemacro,mezzoandmicroparadigm.

Macro:CollectiveWellBeingDisabilityimpactstheindividualandtheentirefamilyunithoweverthisisevenmoreevidentwithinacollectivistculturesuchasCambodia.Itisclearthatwell-beingissharedcollectivelywithinthefamilyandespeciallyforboththecarersandofpeoplewithdisabilities.Peoplewithdisabilitiesarehighlyconcernedabouthowtheirsituationhasimpactedtheirfamiliesincludingtheirchildren,partnersandparents.Similarly,familyandcarersexperiencesignificantpsychologicaldistressduetothelackofaccessibility,uncertainfutureand

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discriminationpeoplewithdisabilitiesface.Thecomplexdynamicthathappenswithinafamilythatexperiencesadisabilityistheshiftinrolesandresponsibilitiesandthelackofincome.

Macro:LackofrightsforpeoplewithdisabilitiesPeoplewithdisabilitiesandtheirfamilieshaveverylittleknowledgeandunderstandingabouttheirrights.However,theyaredirectrecipientsofsignificantviolationsofhumanrights.Atpresentthereisaseverelackofadvocacyandprotectionforpeoplewithdisabilitiesandtheirfamilieswithinthecommunityagainstdiscrimination.Careshaveexpressedtheirfrustrationatthelackofauthorityagainstdiscriminationbycommunechiefswithinthevillage.

Macro:Institutional&AttitudinalBarrierInternationalliteraturehasidentifiedtwouniversalnormsthatpeoplewithdisabilitiesadoptinordertosurviveincluding,normalizationandacquiescence(Tower,2003).Normalizationincludesdenyingthedisabilityandtryingtoportrayanimageofnormality(Tower,2003).Thisworldviewoftenheldbygovernmentandthepublicsuggeststhatpeoplewithdisabilityshould“tryharder”andbeabletomeetthesameexpectationsofpeoplewithoutdisabilities(Tower,2003).However,thebeliefthatoncepeoplewithdisabilitieswhoachievenormalitywillbesuccessfulandbegenuinelyacceptedinsocietyisfalse(Tower,2003).Theideaofnormalizationisoftenstrenuous,unachievableandunsustainablebypeoplewithdisabilities(Tower,2003).Theviewofnormalizationcanalsobeconsideredasfundamentallyviewingtheproblemofdisabilitythroughthemedicallens(Dupré,2012).Specificallythemedicalmodelfocuseson“fixing”adiseasewhichcanbehealed(Dupré,2012).

Incontrastacquiescenceisthenormofacceptingtheimageofpeoplewithdisabilitiesasvulnerableandbehaveaccordinglytosocietiesexpectationsinordertobenefitfromthecharityofthecommunity(Tower,2003).However,thisnormperpetuatesthecharitymodelanddrivesthepersonswithadisabilitytoremainvoiceless,disempoweredandtowardslearnhelplessness(Tower,2003).Theacquiescencemodelisconflictingagainstthesocialmodelasthepersonwithadisabilitymustbehaveinanon-conflictingandnon-complainingattitudetomaintainthenorm(Tower,2003).Fromtheresearch,allgroupsofpeopleincludingthepersonswithadisability,familiesandcarers,serviceprovidersandcommunityleadersatalllevelsshareboththeseviewsinterchangeably.However,itismoreapparentamongcommunityleadersandserviceprovidestoencouragetheviewofnormalization.Althoughithasbeenidentifiedthatencouragementisgiven,itisinfusedwiththenotionofnormalization.Inonecase,amotherofayoungwomanwitha

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disabilitysaidthatherdaughterfeltsignificantpainfromherprosthetic,wasunabletomaintaintheworkloadandeventuallyhadtoquit.MostindividualswithadisabilitywhohaveassistivedevicesandhavelearnednewskillsetsremainunemployedandundesirablebymostemployersinCambodia.Thisisespeciallytrueifthepersonwithadisabilityisofoldage.

Itispossiblethatcommunitymembersandserviceprovidersholdtheviewofnormalizationataverysuperficiallevel.Thisshowsthatthereisalackofunderstandingontherealityofthelivedexperiencesandalackofathoughtfulprocessonhelpingpeoplewithdisabilities.Aspeoplewithdisabilitieseventuallyrealizethatthenotionofnormalizationisfutile,theywillreverttothenormofacquiescence.Participantshaveallidentifiedthatthegovernmenthaslittleornorealinvolvementinsupportingpeoplewithdisabilities.Itisimportanttonotethattherearedifferentdegreesofacquiescenceamongpeoplewithdisabilityasameansofsurvival.

Itisimportanttorecognizethatoftenpeoplewithdisabilitiesareamongthosewithalowlevelofeducationandwereinjobsthatdemandedphysicallaborsuchasfarming.Thelackofalimb,softskillsandeducationleavethepersonwithadisabilitywithverylimitedjobopportunities.Additionally,thegrowingcapitalistandmarketeconomyinCambodiacontinuestoemphasizethevalueofpeopleascommodities.Alongwiththelackofadvocacyfortherightsofpeoplewithdisabilities,thesubstantialenvironmental,institutionandaltitudinalbarriersmakeobtainingajobalmostimpossibility.

Mezzo:TheConceptofPity&AttitudinalBarrierThemainconceptofdisabilityinCambodiarevolvesnegativelyaroundthenotionofpity.Thisconceptperpetuatesthenormofacquiescence,thecharitymodelandcontinuestonegatethesocialmodel.Mostpeoplewithdisabilitiesthemselves,familymembersandthecommunitymember’sassociatedisabilitywithcharity.Asaresult,thecharitymodelremainsinfusedincare,accessibilityandrelationships.AsdisabilityinCambodiaisviewthroughthelensofBuddhismandentrenchedpity,thelackofsocialwelfaremakesthenormacquiescenceinevitableandencouraged.

Pityplaysacriticalpartinthelivedexperiencesofpeoplewithdisabilities.Aspeoplewithdisabilitiesareseentobeunabletoengageinareciprocalrelationshipwithsociety,theygeteventuallygetsociallyexcluded.Asaresultofthedistancingrelationships,fewerfriendsandadiminishingsupportnetwork,peoplewithdisabilitiesmustactivelyengagewithinthepitymodeltosurvive.Theabsenceofsupportandgovernmentwelfaremakesthecombinationofpityandthenormacquiescenceinescapableforpeoplewithdisabilities.Thelackof

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alternativeoptionsmakespeoplewithdisabilitiesinCambodiatrappedinacycleofcharityandtheviewofpityandthenormofacquiescencebecomemoreentrenched.Aspeoplewithdisabilitiesengageinthenormofacquiescence,pityandcharitybecomestheidealimageandroleofNGOs.Therearesignificantpreconceptionsandofexpectationheldbypeoplewithdisabilities,families,communityleadersandserviceprovidersforNGOstoprovidefinancialassistance,jobsandgeneralhelptopeoplewithdisabilities.Thisviewthatisheldbyallkeystakeholdersperpetuatesdisempowerment,thecharitymodelandfurtherrelianceoncharity.Fromthesefindings,itisclearthatthesocialmodelasenshrinedintheUnitedNationsConventionfortheRightsofPersonswithDisabilities,andratifiedbytheCambodiangovernment,remainsattheembryoticstageinthecountry.Theconceptsofadaptationofenvironmentbarriers,therenegotiationsofthesocialdefinitionsofpeoplewithdisabilitiesandinversionofdisabilitystereotypesinCambodiaremainminimal(Tower,2003).

Macro:UnemploymentUnemploymentforthepeoplewithdisabilitieshasaconsiderableanddetrimentalimpactonthefamilyspecificallypartnersandchildren.Itisthenormthattwomembersofthefamilyareremovedfromtheworkforce,includingthepersonwithadisabilityandthepartnerbecomingfulltimecarers.Amajorreasonofthedoublelossofincomeiscontributedtotheenvironmentalbarriersandlackofappropriatefacilitiesinruralhomes.Specifically,theconstructionsofruralhomesaredevoidoftheassistivedevicesavailableintheGlobalNorththatmakelivingindependentlyanimpossibleoption.Therefore,notonlyarethepartnersremovedfromworktobecomefulltimecarers,butalsotheroleofcarersisextremelyimportantandmuchmorelaboriouswhencomparedtotheGlobalNorth.Oftentheseadjustmentsareamatterofsurvivalratherthanchoice.

Itisimportanttoconsiderthatloosingassetsandresourcescontinuestominimizeopportunitiesforpeoplewithdisabilitiesandtheirfamiliesandisamajorcontributortoalossofstatus,lowself-esteem,socialdisintegrationandpsychologicaldistress.Whenpeoplewithdisabilitiesandtheirfamiliesenterthecycleofpovertytheybegintoexperiencealackofbasicneeds,alackofsupport,alackofsolutionsandalackofopportunitiesforthefuture.Anexampleincludeschildrenneedingtoquitschoolinordertohelpprovideforthefamily.Inotherinstances,thelackofbasicneedsmeanspoorqualitymealsandlivingconditions.Theseaspectsmakesindividualswithdisabilitiesandtheirfamilieslooseconfidence,becomevulnerabletosicknessandobtainmorediscrimination

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asaresultofbeingpoor.Insomecasesfamiliesarerequiredtosellalltheirvaluableassetsandbeginordertosurvive.Itisclearthatdisabilityperpetuatesandprolongspovertyandisidentifiedasamajorsourceofsignificantpsychologicaldistressandfamilyconflictforindividualswithdisabilitiesandtheirfamilies.Itisalsounderstandablethatincomeisseenasthesolutionfortheirpsychologicaldistress.

Mezzo:Community&AttitudinalBarrierThecommunityhasbeenidentifiedasamajorsourceofsocialexclusion,discriminationandstigma.Povertyandbeingunabletoparticipateinareciprocalrelationshipwiththecommunitywasalsoidentifiedasareasontosocialisolation.Specificallythisincludestheabilitytobeabletocontributetophysicallaborsuchasbuildingroadsandfinanciallycontributingtosocialevents.Theviewthatpeoplewithdisabilitiesareassociatedwithbegging,areunabletophysicallycontributeandrequirepityfromthecommunitybecomesamajorhindrancetowardssocialexclusion.Forexample,peoplewithdisabilitiesexpressedthattheyare“cutoff”,refrainedandareexcludedfrominvitationstosocialeventssuchasweddingsandtraditionalcelebrations.

Thispertinentviewofneedingpityisalsoamajordeterrenceforpeoplewithdisabilitiesastheyconsciouslyavoidattendingspecialceremoniesatthepagodaoreventsduethisparticularstigma.Althoughtherearesomecaseswhenthepersonwithadisabilityiswillingtohelp,thereseemstobealackofappropriateopportunitiestoactionthis.Thisisolationdoesnotonlyinvolvetheindividualbutoftenthewholefamily.Asaresult,theentirefamilyexperiencesexclusionfromcivilsocietyandpsychologicaldistress.Specifically,thefamilydescribesthatpeopleavoidtalkingtothematsocialevents.

However,becomingsociallyisolatednotonlylargelyimpactsonthepsychologicaldistressofpeoplewithdisabilitiesbutalsobecomesabarriertoaccessingcare.Thecommunityhasalsobeenidentifiedasasourceforaccessingsocialservices.Asaresult,itisimportanttonotethatbeingsociallyexcludedfromthecommunitycanmeanthatpeoplewithdisabilitiesandtheirfamiliesareexcludedfromnecessarysocialservicesthatareprovidedthroughcommunityleaders.Forexample,thelacksocialnetworksimpactongettinginformationregardingtreatment,whichareoftenpassedthroughwordofmouth.TherearealsoothercasesofpeoplereceivinghelpsuchastransporttoPRC.OthersamplesincludenotbeingabletoobtainservicessuchasgettingIDpoorcard.

Participantshaveidentifiedthattheypurposelydenyattendingeventsasaresultofbeingteasedordiscriminatedagainstbythecommunity.Oneparticipant

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identifiedthatshedidnotwanttotravelanymoreandisunabletoparticipateinhouseholdactivities.

Mezzo:Community&DiscriminationThediscriminationfromthecommunityissignificantagainstthechildwithadisability.Oneexampleusedwasthattheneighborsdidnotallowtheirchildrentoplaywiththechildwithadisability.Theassumptionwasthatthedisabilitywouldtransfertotheotherchildren.Thistypeofdiscriminationequallyaffectsboththemotherandfatherofthechildwithadisability.Therearesomecaseswhenthecommunitysaystotheparentsthatthechildwithadisabilitywillneverrecover.Inonecasetheparentwastoldtoputthechildawayinacenterandthatthechildwillbeaburdentothefamilyinthefuture.Despitesignificantdiscriminationbyneighbors,allcarerssaythattheywouldnotgiveuponcaringforthechild.Additionally,discriminationdoesnotaffectthewillingnesstocareforthechildbutpsychologicaldistressimpactsthequalityofcare.

Mezzo:RolesandResponsibilityAnemergingthemethathasariseninthisresearchistheperceivedroleofmaleandfemaleintheCambodiacontextandhowtheyimpactpsychologicaldistress.Thereisathemearoundmaleswithadisabilityaboutthepsychologicaldistressasaresultofthewifeneedingtobecomethebreadwinnerandthemalenotbeingabletoprovideandsupportthefamily.Specificallythisincludesnotbeingabletoprovideforthechildren’seducation.IncontrastacommonroleforwomeninCambodiaistobeasupporterinthefamily.Asaresult,therewasamajorthemeofblamingoneselfforbeingreliantamongwomenwithdisabilities.Itseemslikebeingdependentandrelyingonfamilymembersisasignificantsourceofpsychologicaldistress.Thereseemstobeguiltandself-blamethatisconnectedtobecomingreliantonothers.Thismaybedirectedtotheroleofwomenhavingtheroleofasupporterandhavingadisabilityisadirectcontrasttothis.Althoughthishasbeenmentionedsomeparticipantsstatedthatpsychologicaldistresscamefromalackofhavinganyonetodependonandthelackofsupport.Thelackofhavingsupportcanpreventparticipantsinaccessingcare.Itisalsoimportanttoconsiderthatcarersandwomenwithdisabilitieshavemultipleroleswithinthefamilyandarenotisolatedtojustcaringforthepeoplewithdisabilities.Therecouldbetheadditionofasickchildorageingparents.InadditiontothisistheKhmerexpectationforwomentoserveandlookafterparents.Asaresult,theycanalsobecomeextremelyrestrainedintheirabilityto

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doanyotheractivity.Oneexampleincludesthecarernothavingenoughtimetoeat.

Mezzo:LackofeducationCambodianswithalowlevelofeducationmakejobopportunitieslimitedtohardlaborsuchasfarming..Asaresult,peoplewithdisabilitieswiththelackofeducationoralowlevelofeducationareatanextremedisadvantagewhenapplyingforjobs.Oneparticipantidentifiedthattheyfelt“extremelystuck”andsignificantpsychologicaldistress.Therefore,itisimperativethatpeoplewithdisabilitiesreceiveeducationtohelpbreakthecycleoflackofopportunitytowardsemployment.

Micro:DailylivingexperiencesAninterestingthemetoconsideristhedifficultythatpeoplewithdisabilitiesfacewiththeirpersonalcaresuchwhenneedingtousetoiletswithaccessissueslinkedtothedevelopmentalcontext.Thisincludesconsideringthelackofinfrastructureandsignificantenvironmentalbarrierswithinruralareas.Asaresult,thisisamajorcauseofpsychologicaldistress.Itisimportantthattheseverityofdisabilitywillhaveanimpactanddeterminethelevelofpsychologicaldistress.Participantshaveidentifiedthatdespitehavingprostheticstheenvironmentalbarriersstillmakelifeextremelydifficultforpeoplewithdisabilities.Thisincludespoorlybuiltroads.Similartoadaptingtolimitation,manymaleswithadisabilityexpressedthegriefandlossoftheirpreviouslifeandtheirabilitiesandskillspriortotheimpairment.

Peoplewithdisabilitiesandtheirfamiliesalsofaceadisappointmentintheirpersonalandprofessionalgoals.Forexample,bothparents(husbandandwife)initiallywantedtobecomeatailorandmotorbikerepairerbutnowbothhavehadtostoppursuingthisasaresultoftheirchildwhohasadisability.

Micro:CarersBeingacarerforapersonwithadisabilityisahighlydemandingrolephysicallyandemotionally.Carersarenotlimitedtopartners,whoareoftenfemale,butchildrenandageingparents.Itisimportanttoconsidertheextremelackofbasicneeds,socialsupportandenvironmentalbarriersKhmerpeopleface.Asaresult,carersforpeoplewithdisabilitiesinadevelopmentalcontextareextremelydifficultyandwilllookverydifficultcomparedtotheGlobalNorth.Carersareoftenrestrainedandhavealimitedamountofsociallifeandbecomeisolatedfromthecommunity.Itisimportanttoconsiderthelackofinfrastructure,whichmakescaringforchildreninruralhomesextremelydifficult.

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Carersarepushedthelimitintermsoftheroleasacarer.Onehasmentionedthatshehadnotimetorelaxorsleep.Itisalsoimportanttoconsidertheeffortrequiredinmaintainingthetreatmentforthechildincludingtravellingtimeandlossofopportunitytowork.Carersareoftenneeded24/7duringthedayandthenightforthechildrenwithcomplexneedsasthechildmaybecryingallnightrequiringthemothertosoothethechild.Sometimesthecarermayfeelunwellyetareunabletocareforthemselvesasaresultoftheexcessiveworkrequiredtocareforthechildwithadisability.Forcarerswithsmallbabieswhoarerequiredtoworkasaresultofhavingnopartner,takethebabiestoinappropriateworkenvironmentsthatmayaffectthechildandthepersonworking.Forexample,mothershavethechildwithadisabilityonherbackinthehotsunwhilefishing.Carerssaythatthefulltimeroleofcarermakesthemlacktheenergytoworkduringtheday.Althoughthecarerspendsthemosttimewiththepersonwithdisability,itseemsthatfamiliesonlyengageinencouragement,financialsupportandphysicalcareforthepeople.ThereisalackofevidencesuggestingthatfamiliesinCambodiaprovideadequateemotionalandmentalhealthsupport.

Micro:FamilyFamilywasexpressedasamajorconcernforallgroups.However,itisimportanttoconsiderthecollectivistKhmercultureandthegreateremphasistotakecareofoldageingparentswhichmaycauseagreaterdegreeofpsychologicaldistress.Asaresult,theinabilitytoadheretotheseexpectationscausesasignificantfeelingofshameandembarrassment.

Anotherexampleoffamilyexpectationwasthatyoungmothersweredisappointedabouttheirchildrenwithadisabilitycomparedtowhattheyhaveexpectedforthem.Thisincludesgrievingfortheirpotential,futureandtheexpectationtohavea“normal”child.Similarly,thelackofknowledgeabouttherightsforpeoplewithdisabilityandthelackofwelfaresupportforpeoplewithdisabilitiesmakethe“unknownfuture”ofthesechildrenacauseofsignificantpsychologicaldistressformothersandcarers.Itispossiblethatthisexpectationisrelatedtotheexpectationofthechildbeingabletotakecareofthefamilylaterinlife.Inonecasethemotheridentifiedthatthesignificantpityshefeltforherchildmadeherconsideredcommittingsuicide.Thiswasalsolinkedtotheexpectationthatthechildwouldgrowuptohaveaneducation.Sheconsideredthatherchildhavingadisabilitywasamajorlost.Familyconflictwasalsoraisedastheyexperiencearguing,clashing,wifegettingangryandblamingthepersonwithadisability.Insomecases,thecarersexperiencedadivorceasaresultofhavingachildwithadisability.Specificexamplesincludethehusbandnotlisteningtothewifeorhelpingwiththecare

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ofthechildwithadisability.Womenwithdisabilitiesexperiencesignificantfamilyconflicttothepointofdivorce.Othertypesofconflictincludesayingbadwordstoeachother,angertowardseachother,clash,husbandstopworkingandparticipantsneedingtosleepelsewhereasaresultoffamilyconflict.

Familydiscriminationandstigmaoftenhappenfromthoseclosesttothefamilyincludingcloserelativesandneighbors.Discriminationofthechildwithadisabilitycanhappenamongsiblings.Othertypesofdiscriminationbyneighborsandcloserelativecanincludebeingcallednames,beingpesteredbycuriousneighborsandbeingtoldthatthepersonwithadisabilityisnotworthfindingtreatment.Thereisalsoathemethatrelativesdistancethemselvesfromthefamilyasaresultofthedisability.Itisunsurewhetherthisdistancingissimilartothedistancingthatalsohappensasaresultofpoverty.Thishasbeenidentifiedasasourceofmajorpsychologicaldistress.

PositiveMentalHealth

PeerSupport&DisabilityCultureTheconceptofdisabilitycultureistheidentificationofvalues,beliefsandexperiencessharedamongpeoplewithdisabilities(Tower,2003).ItisclearfromthefindingsthatthePhysicalRehabilitationCentre(PRC)isaplacethatembodiesthedisabilityculture.Mostrespondentsdescribefeelingrelievedwhentheyareabletosharetheirstoriestothosewhohavesimilarexperiences.Specifically,motherswithchildrenwhohavecongenitalimpairmentsweregreatlyencouragedwhentheysawimprovementsforotherchildrenwithsimilarimpairments.Similarly,peoplewithamputationswhoseeotherswithprostheticsbecomehopefulthattheywouldbeabletowalkagain.

EncouragementThegreatestsourceofinformalpsychologicalsupportidentifiedbyallparticipantsisencouragement.However,theencouragementgivenreinforcesthenormofnormalization.Thereisuncertaintywhetherthisencouragementhelpsorhindersthepsychologicaldistressofpeoplewithdisabilities.Yet,itispossiblethatthehumanconnectionisamorevaluableexperiencethanthewordsspokenthroughencouragement.Despite,encouragementisalargethemeinpositivementalhealthithasbeenidentifiedthatmostpeoplewithinthecommunityandevenclosefamilymembersarepoorandareunabletocontributewithmaterialneeds.Asaresultwordsofencouragementbecomealargepartofpositivementalhealth.Encouragementmaycomefromclosefamilymembers,relativesandindividualswithinthecommunity.

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PsychologicalDistress

Lowvalue/lowselfesteemAlargemajorityofpeoplewithdisabilitieshaveanegativeviewofthemselves.Theysaythingssuchas"noonelikesme","mymotherhatesme","Iamlazy","Ithinkbadaboutmyself".However,itseemsthattheirsenseofvalueisentirelybasedontheirabilitytoperformandtheirabilitytorecover.Apartfrombeingabletowork,theyhaveverylittlesenseofintrinsicvalue.Thisgivesinsightintothelackofadvocacyandawarenesstherightsofpeoplewithdisabilities.Astherealityofobtainingajoborregainingajobremainsextremelydifficult,thefailuretodosomaycontinuallyreinforcealowself-esteemofbeinginvaluableanduselessinsocietyandbecomeamajorsourceofpsychologicaldistress.

Disability,IncomeandSocialLife,CommunityandOtherRelationshipsPsychologicaldistresscausedbythedisability,income,thecommunityandothercloserelationshipsincludesfeelingofalossofconfidence,lowself-esteem,anxiety,feelingstuck,upset,annoyed,loneliness,sadness,worry,unabletosleep,alcoholconsumption,suicideideation,regret,responsible,anger,tense,difficultandlackinginmotivation.

CommunityThereisasignificantdisparitybetweentheeffortsmadetoaddresstherightsofpeoplewithdisabilitiesbythecommunityleadersandtheimpactithasonpeoplewithdisabilitiesandtheirfamilies.DespiteeffortsbythecommunitychiefsaidfundraisefromNGOsandstakeholderstoimprovethecommunity,helpmakelifeeasierforpeoplewithdisabilitiesandreducepoverty,thisisseldomthereality.Asaresult,thereisariskthattheneedsandpsychologicaldistressofpeoplewithdisabilitiesareignoredthroughouttimewhileeffortseemstobemadeamongcommunitystakeholders.

Although,thecommunityleadermentionedthatheinformshisteamtopayattentionnotignoreandtreatpeoplewithdisabilitiesandtheirfamiliesequally,thisisalsonotexperiencedinreallife.Incontrastpeoplewithdisabilitiesandtheirfamiliesexpressthatthecommunityisamajorsourceofdiscriminationandpsychologicalstress.Yet,acommonproposedsolutionremainsthenormofnormalization.Acommonsuggestionbycommunitymembersandserviceprovidersisthatifpeoplewithdisabilitiesbecomesuccessfulthatthecommunitywillhonor,congratulateandfindpleasurewiththem.Thereisnoevidenceofthisfromthedata.

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6.Recommendations

Recommendationsbasedonliteraturereview

ResearchImplications-PsychosocialIssuesTheaimoftheliteraturereviewhasbeentoidentifythepsychosocialneedsofindividualswithdisabilities,togainfurtherunderstandingabouttheirlivedexperiences,andtoidentifyexistingbarrierstoaccessingservices.Thereviewfoundthatthetypeofimpairmentisastrongdeterminantofpsychosocialissues(Palmer,2011).Thereisalargeemphasisonphysicaldisabilityandmentaldisabilities,howeverthosewithanintellectualandsensorialimpairmentarelessresearched(Cordier,2014;Coton,etal.,2008;Gartrell&Hoban,2013;Zook,2010).Despitetheirgrowingnumberandinfluenceindecision-making,researchonparentsandcarersofpeoplewithdisabilitiesinCambodiaremainseverelylimited(Cordier,2014;Coton,etal.,2008).Additionally,womenwithdisabilitieswhoexperiencesignificantlydifferentpsychosocialissuesarealsounderresearched(Astbury&Walji,2014).Itisnotunexpectedthatdataregardingcommunitymembersareabsent,yetthisproposesasignificantbarriertowardsunderstandingtheirinfluenceonpsychosocialissues.Moreover,dataofservicesprovidersandindividualswithoutadisabilityisalsomissing.Lastly,therehasbeennoresearchontheissuesexperiencedbythosewithcomorbidimpairmentandillnesses.Asaresultoftheseseveregapsinliterature,futureresearchmustaimtoestablishanunderstandingofthepsychosocialissuesofeachpopulationgroup.Thefindingsshouldbeusedtoframefutureservicesandsupportforthesekeygroups.

ResearchImplications-LivedExperiencesIntheattempttounderstandthelivedexperiencesofpeoplewithdisabilities,alargethemeemergedaroundstructuralbarriersforthosewithaphysicaldisability.Thisincludesthelackofinfrastructurespecificallyinruralhomes,schoolsandevenhospitalsincapitalcities(Vanleit,2008;Zook,2010).Yettherehasbeenminimalmentionofthelivedexperiencesofthosewithothertypesofimpairmentsandthoseofcarersandparents(Cordier,2014;Coton,etal.,2008).Therearecommonideasaroundlivedexperiencesofallpeoplewithdisabilitiesandtheirfamiliesincludingpoverty,stigmaanddiscrimination(Gartrell&Hoban,2013;Palmer,2011;Seponski,etal.,2014).Specifically,mostliteraturehighlightedtheexclusionofbasicrightssuchastherighttohaveeducation,workandparticipateincivicsocietyduetostigma(Astbury&Walji,2014).However,onlyalimitedamountofliteratureexaminedthephysicalillnessandpsychosomaticsymptomsthatareexperiencedduetoamentaldisability(Dubois,etal.,2004;Mollica,etal.,2014).Additionally,onesignificantstudy

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foundgenderspecificissuesofsuchinterpersonalviolence(Astbury&Walji,2014).Therehasbeensomeliteraturethatdrawsattentiontotheimportanceofdailystressorsratherthanhistoricaltraumaasatriggertopsychosocialissues(Cantor-Graae,etal.,2014;Mollica,etal.,2014).Equallyimportant,isthefocusonpsychosocialsufferingwhichstemfromdailystressfulsituationsratherthanhistoricaltrauma(HandicapInternational,2011;Jegannathan,etal.,2015).Thiscanincludeexaminingthesocialenvironmentsthatcreatesdisability,vulnerabilityandsocialinsecurity(HandicapInternational,2011).Despitetheneedtoappreciatethelivedexperiencesofpeoplewithdisabilities,almostallstudiesremainedentirelynegative.Futureresearchmustuseexistingdatatobuilduponamorecomprehensiveunderstandingoflivedexperiencesthatalsofocusesonstrengthsandfactorsthatcontributetopositivementalhealth.Thiscanincludeexaminingpersonalitytraitsandfactorsthatcontributeandmaximizesresilience,self-esteemandoptimism(HandicapInternational,2011).Lastly,thereisaneedformorelocalresearchbeingconductedthroughthelensofCambodianacademics,whichwillprovideamorein-depthunderstandingoftheculturalcontextandlivedexperiencesofpeoplewithdisabilities(Simcox&Strasser,2010).

ResearchImplications-BarrierstoServicesItisnotsurprisingthattheemphasisonphysicaldisabilityhasresultedinalargevolumeofliteratureonstructuralandenvironmentalbarriersinaccessingservices(Vanleit,2008;Zook,2010).Therearesomedata,whichfocusesonissuessuchaspoverty,institutionalconstraintsandculturalbeliefswhicheffectaccessingservices(Palmer,2011;Seponski,etal.,2014).However,thereremainsanincompleteunderstandingofthetypesofbarriersexperiencedbytherangeofimpairments.However,itisapparentthatservicesareculturallyinsensitiveandlackintegration(Seponski,etal.,2014).Furthermore,itisunclearwhichsupportremainsthemosteffective(Coton,etal.,2008).Aninterestingfindingshowedthateducationandtheawarenessofservicesisamajordeterminantinserviceseekingbehaviorforparents(Coton,etal.,2008).However,thistopicneedstobefurtherexploredacrossalltypesofimpairments.Theseresultsmayprovideagreaterunderstandingonthespecificinterventionsinordertobridgeandclosethebarrierstowardssupport.Furtherresearchmustbeundertakentoascertainwaystofurtherempowerpeoplewithdisabilitiesandtheirfamiliesinovercomingbarriersandengaginginservices.Explorationoftypesofsupportbeyondphysicalrehabilitationandacutepsychiatricservicesisrequired.Thiscanincludeexaminingcommunitysupportinterventionandprevention,personalrecovery,psycho-educationandcommunityrecoveryframeworks(Hein,2015).

ResearchImplications:RecoveryFramework

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TherecoveryframeworkthatfocusesonlivingwithamentalhealthproblemisadvocatedasanimperativeframeworkforvictimsoftraumainCambodia(Hein,2015).Althoughthisconceptisrecognizedworldwide,onlyoneliteraturebyHein(2015)hasproposedthisasasolutiontopsychosocialwellbeinginCambodia(Wyder&Bland,2014).ThisalternativeframeworkproposedbyHein(2015)inhiscriticalanalysisofPTSDinCambodia,viewsPTSDasacollectiveexperiencethatisshapedbysociety.Specifically,themeaningassociatedwithtraumaissignificantlyinfluencedandconstructedbyculturalnormsandpowerrelationships(Hein,2015).Additionally,theauthorarguesthatwhetheranexperienceistraumaticisentirelydependentonthesubjectiveexperiencesoftheindividual(Hein,2015).Therefore,thesubjectivetraumaticexperienceiscentralinpredictingapositiveornegativementalhealthimpact(Hein,2015).Fromthistheoreticalviewpoint,severalauthorshighlightthataparadigmshiftfromclinicalcuretoclientempowermentandpreventionisrequiredinservicesandpolicies(Cantor-Graae,etal.,2014).

InadditiontotheoneononenarrativetechniqueusedinWesternrecoverymodel,Hein(2015)promotesthesharingofcollectivestorieswithinacollectivetherapeuticrelationship(Hein,2015).Yet,thelogisticalchallengeremainsthesevereshortageofmentalhealthservicesaswellasthestigmaassociatedwithseekinghelpwhichhaspreventedthefulleffectivenessofthiscollectivemodel(Hein,2015).Moreover,thereremainsasignificantamountofdebateregardingtheriskofre-traumatizingandpsychologicaldamagewhensharingthestories,especiallyinassociationwiththeKhmerRouge(Hein,2015).Therefore,acollectiverecoverymodelremainsdormantduetoethicalandstructuralchallengesinCambodia(Hein,2015).Onthatnote,Hein(2015)arguesthateducationandempowermenttoengageinself-supportrecoveryisthesolutiontomentalhealthrecoveryinCambodia.

ResearchImplications:CulturalSensitiveFrameworkPovertyalleviation,ahumanrightsframeworkandaculturallysensitiveframeworkhavebeenregardedascentraltoprovidingeffectivementalhealthservicestopeoplewithdisabilities(Astbury&Walji,2014;Palmer,2011;Seponski,etal.,2014).TheresearchfindingsfromSeponski(2014)recommendsthatpovertyelimination,enhancingfamilyrelationshipsandimprovingthephysicalhealthofindividualsshouldbeconductedinconjunctionwiththerapeuticinterventions(Seponski,etal.,2014).Itisalsorecommendedthatbasicmentalhealthcounselingandpsycho-educationwithinacommunitycontextwouldbemoreappropriateinCambodiaratherthanindividualandhighlyspecializedmentalhealthtreatments(Seponski,etal.,2014).SpecificallythisincludesagrouptherapymodelwhichuniquelyaddressthecorruptionwithinpoliticsinCambodia(Seponski,etal.,2014).Additionally,themental

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healthservicesmustupholdprocessesthatpromotefairness,equalityandadvocacyascentralwhenprovidingservices(Seponski,etal.,2014).Thisincludespromotingandfightingfortherightsofpeoplewhoaremostmarginalized,seekingtohelpalleviatetheseverepovertyandattemptingtochangepublicpolicy(Seponski,etal.,2014).

ResearchImplications:IntegratedServicesTherehasbeensignificantemphasisfortheneedforanintegratedmentalhealthcaresystemthatisunderpinnedbyevidencebasedresearch,inclusivityandculturalsensitivity(Coton,etal.,2008;Gartrell&Hoban,2013;Hein,2015;Jegannathan,etal.,2015).Specifically,thereneedstobeservicesthatexaminethecontextofsocio-historical,socio-economicandculturalsystemsthatcontributetodisabilityandmentalhealth(Seponski,etal.,2014).Moreover,thereneedstobemoreresearch,whichvalidatestraditionalapproaches,suchastraditionalhealing,self-treatment,familyconsultationandspiritualityincommunitymentalhealth(Coton,etal.,2008;Mollica,etal.,2014).Akeyargumentincludestheunderstandingofculture,beliefsandexpectationthattraditionalhealerscanprovide(Coton,etal.,2008).However,asthemajorityofpeoplewithdisabilitiesandindividualssufferingfrommentalhealthissuesliveinruralareasandareextremelypoor,anemphasisoncommunitypreventionandcareiscentral(Gartrell,2010).

Recommendationsbasedonstudyfindings;

1. EducationonmentalhealthbyserviceprovidersincludingLouvainCooperationandHandicapInternational.

Educationonthementalhealthneedsofpeoplewithdisabilitiesandtheirfamiliesforallstakeholdersisparamount.

1. Educationontheimportanceofmentalhealthalongsidephysicalhealth.2. Educationforpeoplewithdisabilitiestounderstandhighlevelsof

psychologicaldistress,whicharemostlyignored,unknownandunaware.3. Assistingfamiliesinunderstandingthepsychologicalneedsofpeople

withdisabilities.4. Educationonwhatmentalhealthisandthepsychologicalneedsofpeople

withdisabilitiestocommunitymembersandserviceproviders.5. Educationontheexpectationofmentalhealthcareisandlookslike.Many

individualswithdisabilitiesandtheirfamiliesexpectmedicationasaformoftreatment,ashiftinthiswouldbebeneficial.

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6. Educationontheresultsofmentalhealthrecoverytoberealistic.Thisincludesspecifyingthattheobjectiveofthetreatmentbecentredonrelationshipofsupportandrecovery.

2. Educationaboutdisability(DisabilityCreationProcess)byServiceProvidersincludingHandicapInternational.

Thecurrentperceptionofpeoplewithdisabilitiesremainsunderpinnedbythecharityandmedicalmodel,whichperpetuatesstigma,discriminationandreaffirmsnegativestereotypes.

1. Therealsoneedsanequalamountofeducationtoallkeystakeholders

regardingthelivedexperiencesofpeoplewithdisabilities.Althoughsomeserviceproviderswereabletoidentifysomecorrelationbetweenexternalenvironmentsandpsychologicaldistress,theirknowledgeremainedrudimentary.

2. TheDCPisahighlyusefultoolthatcanbeusedtodemonstratethecomplexityofdisabilityandhelpkeystakeholderstodevelopahighlevelofawarenessoftheirroleandofotherfactorsthatimpactpeoplewitharangeofimpairmentsincludingthosewhofacementalhealthproblemsandtheirfamilies.Forexample,povertyanddomesticviolenceareoftenlinkedtogether.

3. Educationonrightsforpeoplewithdisabilities(SocialModel)byServiceprovidersincludingHandicapInternationalandpeoplewithdisabilitiesthemselvesaspeereducators.

Educationonthesocialmodelneedstoincreasetoshiftthedominantcharityandmedicalviewofdisability,whichcontinuestoperpetuatesignificantstigmaanddiscrimination.

1. Thiseducationisrequiredforallkeystakeholdersasneitherpeoplewithdisabilitiesnorserviceprovidersgenuinelyunderstandtherightsofpeoplewithdisabilities.

2. Mostimportant,thiseducationneedstoprovidehowthesocialmodelcanbeimplementedonthegroundlevelandwithinthedevelopmentalcontext.Theproblemremainsthelackofunderstandingonimplementationofpolicies.

3. Thiseducationalsoneedstomovebeyondthedisabilitysectorandtoothergovernmentsectorssuchaseducation,healthandemployment.

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4.Advocacyandawareness(EducationalandCommunityLevel)byserviceprovidersandthecommunityandDisabledPeoplesOrganizations(DPOs).Advocacyandawarenessshouldhappenconcurringlywitheducationinawaythatisengagingandinvolvesdialogue.One-waycommunicationthroughmediaoutletssuchasTV,radioandpostersmaybehavelimitationandbeineffective.However,raisingawarenessinaneducationalwayatthecommunitylevelhasbeenidentifiedasmoreeffective,especiallyforpopulationswithlow-leveleducation.

1. Allkeystakeholdershaveexpressedraisingawarenessontherightsofpeoplewithdisabilitieswasparamount.

2. Raisingawarenessonthelivedexperiencesofpeoplewithdisabilitiesandtheirfamilies,especiallyonpsychosocialdistress,discrimination,familyconflictanddomesticviolence.

3. Raisingawarenessonthelivedexperiencesofcarers.4. Advocatingfortherightsofwomenwithdisabilitiesespeciallywithinthe

family,healthcareandemployment.5. Advocatingonprotectingwomenwithdisabilitiesfromdomesticviolence

andsexualabuse.6. Awarenessonmentalhealthandde-stigmatisation

5.TrainingbyNGOs/serviceproviders,especiallyHandicapInternationalandLouvainCooperation.Theinabilitytoimplementlawsandpoliciesforpeoplewithdisabilitiesinawaythatisfunctionalhasbeenhighlightedbyserviceprovidersasamajorbarrier.Additionally,itisimportanttorecognizethatpeoplewithdisabilitiesalsorequiretrainingandpreparationwhenmeetingwithserviceprovidersinhealthsettings.NGOshavebeenconsideredastheprimesourceforthistrainingandtheexpertforservicesforpeoplewithdisabilities.ServiceProviders

1. Trainingneedstoinvolvehigh-rankingofficialswherethedesignofpoliciesandprojectsoccur.

2. Trainingneedstofacilitateanenvironmentwherehigh-rankingofficialscanhavedirectcontactpeoplewithdisabilities.Thisallowsthemtoaltertheirperspectiveofinabilitytoempowermentandbreaktheperceptionof“usandthem”.

3. Training/coachingfrontlineserviceprovidersonhowtotreatpeoplewithdisabilitieswhenprovidinghealthservices.

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PeoplewithDisabilities 1. Preparingpeoplewithdisabilitiestobecomemoreawareofhowthey

presentthemselveswithsoftskillsenhancementwhenaccessingservices.2. Trainingpeoplewithdisabilitiesoncommunicationandhowtonavigate

communicationbreakdownwhileaccessingservices.

6.Inclusionofpeoplewithdisabilitiesinallprocessesbyallserviceprovidersandthecommunity.Peoplewithdisabilitiesareoftenforgottenandleftoutonprocessesthatinvolveservicesforthem.

1. Peoplewithdisabilitiesneedtobeincludedintheeducation,traininganddesignofprogramsandpoliciesthatinvolvesthem.

2. Encouragepeoplewithdisabilitiestoexpresstheiropinionsandideas.3. Thisistoadheretotherightsofpeoplewithdisabilitiesandhelpensure

servicesarepracticalandfunctionalinreality.4. Tokeeppeoplewithdisabilitiesattheforefrontandinthemindsofall

keystakeholders.

7.Peer&FamilyModelbyserviceproviders.Almostallparticipantshaveidentifiedthatrelationshipswithotherswhosharesimilarexperiencesandinformalencouragementarethegreatestsourcesofpositivementalhealth.Therefore,relationshipsatthePRC,athomeandwithinthecommunityshouldbepromotedandencouragedasamajorsourceofmentalhealthsupportforpeoplewithdisabilitiesandtheirfamilies.Assuch,furtherconsiderationsforserviceproviderstosupplyamechanismforthefollowingapproaches:

• Familysupport,familynetworksandfamilygroups.• Peersupportandpeergroups.

Additionallyconsiderationscouldbemadeintermsof:

• Fosteringpositivementalhealth• Behaviourmanagement• Conflictresolution• Protectionissues(i.e.domesticviolence,intimatepartnerviolence)

8.Integratedservicesduringdesignandimplementationbyserviceprovidersandcommunityleaders.Aspsychologicaldistressisconnectedtopsychosocialissues,itiscriticaltoconsideraholisticandintegratedapproach.Asdisabilityiscomplexandisa

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resultofexternalandinternalenvironments,mentalhealthservicescannotbeinisolatedfromassistanceforlivelihood,employmentoreducation.Itisequallyimportanttoconsiderprovidingmentalhealthassistanceinsettingssuchaswithinone’shome,withinthecommunityoratthehealthcentersandhospitalsaswellasPRC.Indesigningaserviceforpeoplewithdisabilitiesservicesmustconsiderhowtoavoidadditionalexpensesandopportunitycostsforthefamily.

1. Stigmaassociatedtomentalhealth2. Gendersensitive3. Culturalsensitivity4. Time&costtotravel5. Opportunitylostforthepersonwithadisabilityandtheirfamily6. Opportunitylostforthecarertogotowork7. Dependentsathome8. Availabilityofcarer9. Accessibility10. Staffhavingknowledgeaboutpeoplewithdisabilities

10.BetteraccessibilityforPeoplewithDisabilitiesbyserviceproviders. Therecontinuestobepooraccessibilityforpeoplewithdisabilitiesinhealthcentersthatprovidemedicalandmentalhealthtreatment.Specifically,furtherconsiderationneedstobegivento:

1. Ramps,toiletsandwaitingareaforpeoplewithdisabilities.2. Appropriatesignageforpeoplewithothertypesofdisabilities.3. Asystemthatisuser-friendlyandprioritiespeoplewithdisabilitiesand

theirfamilies4. Communicationinformationtoreachpeoplewithdisabilitiesandtheir

carerinaccessibleformsusingpictorial,brailleandsymbols.Aswellassystemsandtrainingofstafftocommunicateandworkwithpeoplewithdisabilities.

5. Provisionofoutreachcommunityservicesthatreachouttothemostvulnerablewhocannotgettotheservices

10.ResearchThereneedstobefurtherconsiderationonthepsychologicaldistressofothertypesofdisabilitiesbesidespeoplewithphysicalimpairments.ThesemayincludepeoplewithothertypesofimpairmentsbutalsoinothercontextsincludingthosewhodonotreceiveservicesfromthePRCandinotherprovinces.

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Currentresearchopportunitiesinclude:• Theprevalencerateofpsychologicaldistressofpeoplewithothertypes

ofimpairments.• Theprevalencerateofmentaldisordersamongpeoplewithphysical

impairments.• Theprevalencerateofmentaldisordersamongpeoplewithdisabilities

acrossalltypesofimpairments.• TheabovetopicstargetingpeopleoutsidetheservicesofthePRC.• Astudyonbarriersandfacilitatorsforfamiliesofpeoplewithdisabilities.• Anin-depthstudyonaccessibilitytoservicesforotherprogramswithin

HI.• Astudyonotherservicesthatpeoplewithdisabilitiesandtheirfamilies

accessbesidesthePRC.

END

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7.Appendix

Appendix 1 FocusGroupDiscussionGuide:Peoplewithphysicalimpairment(12questions):Identificationofpsychologicaldistressandpositivementalhealth:1. Howdoyoufeelaboutliferightnow?2. Pleasedescribewhathealthandwellbeingistoyou?

a. Whatmakesyouhappy?i. Physicalandmentalwell-being,diseasefree,fullofphysicalmovementandfeelinghappy

b. Whatmakesyousad(anxious,depressed)?i. Illness,nowork,discrimination

3. Pleasetellmewhatyouthinkdistressmeans?a. Wheredoesfeelingsofsadness,anxietyanddepressioncome

from?i. Thinkingalot,karma,infections,poverty,naturaldisasters,lackofemployment,lackofincome.

b. Howdoyouthinkfeelingsofanxiety,sadnessordepressioncanbecured/supported?

i. Traditionalhealers,meditation,medicine,money,encouragement

c. Whatfeelingsdoyouthinkhelpustobehappyinourlives?i. Optimism,self-esteem,confident

4. Howdoesanxietyandsadnessanddepression…(psychologicaldistress)affect/impactonyourlife(well-being)?

i. Emotionally:upset,frustration,lackofmotivation,exclusion,isolation

ii. Body:Stressful,tired,exhausted,overwhelmed.iii. SelfEsteem(Stigma):Feelingbadasaresultofnegative

perception,believinginkarmaandfeelingcondemned,feelingtheneedtocompensate.

5. Howdoeshavingoptimism,selfesteem…(positivementalhealth)affectyouandyourlife?

i. Betterselfesteem,socialisingLivedexperienceswithpsychologicaldistressandpositivementalhealth(sociallife,relationships,family)6. Howdoessadness,depression(psychologicaldistress)affect/impactonyour

sociallife?

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i. Limitedaccesstoeducation,work/livelihoodactivitiesandparticipationincommunity/sociallife(sport…).

ii. Difficulty,unabletohelpothers,one-sidedrelationshipb. Yourrelationships/colleagues/neighbours(positiveand

negative)?i. Impatient,becomingnegative,unabletocontrolfeelings,lonely

c. Yourfamily(positiveandnegative)?i. Economicgrowth,lesshappinesscomparedtootherfamily,stigma–remindedthatfamilyhasadisability

ii. Lackofsavings,lossofincome,lackofinclusionindecisionmaking

7. Howdoesyourcommunityhaveaneffect/impactonyourfeelingsofsadnessoranxiety(psychologicaldistress)?

i. Lossofopportunitytovolunteerlackofsupportfromneighboursordiscrimination/stigmaorsaybadword/impairment

8. Whatareyourexperiencesinyourcommunity,howdoesyourcommunityhaveaneffect/impactonyourfeelingsonyourself-esteem,andhappiness(positivementalhealth)?

i. Encouragement,feelingsupported

Accessandbarrierstoservices(pleaseconsiderservicesbeyondthePRC)9. Whattypesofsupportdoyoureceiveforyoursadnessoranxiety

(psychologicaldistress)?i. Awareness/inclusion/andemployment/counselling/medicine

b. Whatthingsmakeitdifficultforyoutoaccesstheseservices/support/nosupport

i. Distance,infrastructure,transport,finances,attitude(Discrimination)etc.

a. Whatthingsmakeiteasyforyoutoaccesstheseservices/support/nosupport

10. Whattypesofsupportdoyoureceiveforself-esteem,optimism,happiness(positivementalhealth)?

i. Money,job,yoga,meditation,pagoda,villagehead,church,nosupport

b. Whatthingsmakeitdifficultforyoutoaccesstheseservices/support/nosupport

i. Distance,infrastructure,transport,finances,attitudeetc.b. Whatthingsmakeiteasyforyoutoaccessservices/support/nosupport

11. Whatsupportdoyouthinkyouneedforsadness,anxietyordepressionyoumayfeel(psychologicaldistress)?

I. counselling(someonetotalkthingsthroughandshareproblems

II. groupsofotherpeopletobeincontactwithwhosharecommonproblems

III. medicineIV. familysupportandunderstanding

12. Anyotheradditionallyinformationyouwouldliketoshare?

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Appendix 2 FamilyandCarers(12questions):Identificationofpsychologicaldistressandpositivementalhealth:1. Howdoyoufeelaboutliferightnow?2. Pleasedescribewhathealthandwellbeingistoyou?

a. Whatmakesyouhappy?i. Physicalandmentalwell-being,diseasefree,fullofphysicalmovementandfeelinghappy

b. Whatmakesyousad(anxious,depressed)?i. Illness,nowork,discrimination

3. Pleasetellmewhatyouthinkdistressmeans?a. Wheredoesfeelingsofsadness,anxietyanddepressioncome

from?i. Thinkingalot,karma,infections,poverty,naturaldisasters,lackofemployment,lackofincome.

b. Howdoyouthinkfeelingsofanxiety,sadnessordepressioncanbecured/supported?

i. Traditionalhealers,meditation,medicine,money,encouragement

c. Whatfeelingsdoyouthinkhelpustobehappyinourlives?i. Optimism,self-esteem,confident

4. Canyoudescribeyourexperienceoflivingwithfamilymemberswhohaveaphysicalimpairment?

a. Whatarethenegative/difficultaspects?i. Sad,embarrassed,lowexpectationofincome,discriminationorstigma

ii. Difficulty,unabletohelpothers,one-sidedrelationship,tirediii. Stressful,tired,exhausted,overwhelmed.iv. Feelingbadasaresultofnegativeperception,believinginkarma

andfeelingcondemned,feelingtheneedtocompensate.b. Whatarethepositiveaspects?

i. Happy,proudii. Twowayrelationshipiii. Copingwell……………………

5. Howdoessadness,depressionordistressyoumayfeel(psychological

distress)impactonyourcareforyourfamilymemberwithaphysicalimpairment?

Livedexperienceswithpsychologicaldistressandpositivementalhealth(sociallife,relationships,family):6. Howdoessadness,depression(psychologicaldistress)affect/impacttoyour

sociallife?i. Limitedaccesstoeducation,work/livelihoodactivitiesandparticipationincommunity/sociallife(sport…).

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ii. Difficulty,unabletohelpothers,one-sidedrelationshipb. Yourrelationships/colleagues/neighbours(positiveand

negative)?i. Impatient,becomingnegative,unabletocontrolfeelings,lonely

c. Yourfamily(positiveandnegative)?i. Economicgrowth,lesshappinesscomparedtootherfamily,stigma–remindedthatfamilyhasadisability

ii. Lackofsavings,lossofincome,lackofinclusionindecisionmaking

7. Howdoesyourcommunityhaveaneffect/impactonyourfeelingsofsadnessoranxiety(psychologicaldistress)?

i. Lossofopportunitytovolunteerlackofsupportfromneighboursordiscrimination/stigmaorsaybadword/impairment

8. Howdoesyourcommunityhaveaneffect/impactonyourfeelingsonyourself-esteem,optimismandhappiness(positivementalhealth)?

i. Encouragement,feelingsupported

Accessandbarrierstoservices(pleaseconsiderservicesbeyondthePRC)9. Whattypesofsupportdoyoureceiveforyoursadnessoranxiety

(psychologicaldistress)?i. Awareness/inclusion/andemployment/counselling/medicine

b. Whatthingsmakeitdifficultforyoutoaccesstheseservices/support/nosupport

i. Distance,infrastructure,transport,finances,attitude(Discrimination)etc.

c. Whatthingsmakeiteasyforyoutoaccesstheseservices/support/nosupport

10. Whattypesofsupportdoyoureceiveforself-esteem,optimism,happiness(positivementalhealth)?

i. Money,job,yoga,meditation,pagoda,villagehead,church,nosupport

b. Whatthingsmakeitdifficultforyoutoaccesstheseservices/support/nosupport

i. Distance,infrastructure,transport,finances,attitudeetc.d. Whatthingsmakeiteasyforyoutoaccessservices/support/nosupport

11. Whatsupportdoyouthinkyouneedforsadness,anxietyordepressionyoumayfeel(psychologicaldistress)?

V. counselling(someonetotalkthingsthroughandshareproblems

VI. groupsofotherpeopletobeincontactwithwhosharecommonproblems

VII. medicineVIII. familysupportandunderstanding

12.Anyotheradditionallyinformationyouwould

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Appendix 3 FocusGroupDiscussionGuide:ServiceProviders/communitymembersKnowledgeaboutpsychologicaldistressandpositivementalhealth:1. Whatdoeswell-being(feelinghappyandhealthy)meantoaKhmerperson?

a. Whatmakespeoplehappy?i. Physicalandmentalwell-being,diseasefree,fullofphysicalmovementandfeelinghappy

b. Whatmakespeoplesad?i. Illness,nowork

2. Pleasetellmewhatyouthinkdistressmeans?a. Wheredoesfeelingsofsadness,anxietyanddepressioncomefrom?

i. Thinkingalot,karma,infections,poverty,naturaldisasters,lackofemployment,lackofincome.

b. Howdoyouthinkfeelingsofanxiety,sadnessordepressioncanbecured/supported?

i. Traditionalhealers,meditation,medicine,money,encouragement

c. Whatfeelingsdoyouthinkhelpustobehappyinourlives?i. Optimism,self-esteem,confident

3. Whattypesofmentalhealthproblems(depression,anxiety,stress)doyouthinkpeoplewithphysicalimpairmentshave?

i. Cannotperformworkproperly,otherpeoplerejectthem.ii. Suicidaliii. Unabletoearnmoneyforfamily,thereforefamilieswillnotlook

afterthem.Consideredasoutsiders.

Attitudeonpsychologicaldistressandpositivementalhealth:4. Howdoessadness,stress,anxiety,depression(psychologicaldistress)affect

peoplewithphysicalimpairmentandtheirfamilies?5. Howdoesoptimism,feelingofcontrol,self-esteem(positivementalhealth)

affectpeoplewithphysicalimpairmentandtheirfamilies?

6. Howdoessadness,stress,anxiety,depression(psychologicaldistress)affectpeoplewithphysicalimpairmentsandtheirfamiliesaccessservices?

7. Howdoesoptimism,feelingofcontrol,self-esteem(positivementalhealth)affectpeoplewithphysicalimpairmentsandtheirfamiliesassessservices?

Practicewiththosewhohavepsychologicaldistressandpositivementalhealth:8. Howareyousupportingpeoplewithanxiety,sadness,stress,anxiety,

depression………(psychologicaldistress)whohaveaphysicalimpairment?9. Whatarethechallengesyoufacewhenyouprovidedservices/supportsto

peoplewithphysicalimpairmentandtheirfamilieswhoexperiencesadness,stress,anxiety,depression(psychologicaldistress)?

i. Slowrecovery/progressandlackofmotivation10. Whatarebestwaystosupportpeoplesadness,stress,anxiety,depression

(psychologicaldistress)withphysicalimpairmentandtheirfamily?a. Encouragement

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b. Collaboratewithhospitalstocheckaccessibility11. Whatarethebestwaystosupportself-esteemandoptimism(positivemental

health)inpeoplewithphysicalimpairmentsandtheirfamilies?12. Anyotheradditionallyinformationyouwouldliketoshare?

END

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Appendix 4

Mental Health Survey for People with Physical Impairments

To be completed by field team members. The person completing the form MUST

make it clear in the Disability Type category box what type of impairment the individual has. The information gathered in this interview will help to understand the mental health of people with disabilities. Please ensure the consent sign if formed PRIOR to completing this survey. INTRODUCTION Thank you very much for making time available for this short survey. My name is…… and I am working as a (eg. volunteer) with Handicap International. One of my tasks are assist you complete this survey and clarify any points of concern. This feedback will help us further understand the needs of people with physical impairments. All responses will be confidential so please be open and do not hesitate to express your views. Do you agree to participate in this survey? £ Yes £ No (end of interview) Interviewer: _________________________ Date of survey: _________________________ PART 1: Socio-demographics (please ensure all the following are completed) 1. Name of respondent: 2. Age: 3. Gender: 4. ID file number: 5. Cause of impairment (please tick one):

a. ☐ Landmines/UXO b. ☐ Road traffic/accident c. ☐ Disease d. ☐ Congenital

6. Nationality: 7. ID Poor Card Level: 8. Level of education: 9. Religion: 10. Ethnicity: 11. Location of village: 12. When did you receive your impairment (year): 13. Other health conditions (i.e blood pressure, diabetes): 14. Marital Status:

a. ☐ Married b. ☐ Divorced c. ☐ Widowed d. ☐ Single

15. Role in the family (i.e father, mother, child): 16. How many members are in your household?: 17. Previous occupation of the person with disability before the disability:

a. How much income per month (riel): 18. Current occupation of person with disability (i.e. unemployed, part time work, volunteer): 19. Who is the current income earner:

a. How much income per month (riel):

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Where possible the person with a disability to complete the following sections (if they need support then this can be provided) PART 2: Disability Which of the following statements applies to you? As a person with disabilities, I view myself as….

True False

a. Knowledgeable b. Proud c. A useful member of the community d. A medical case e. Pitiful f. Having poor health g. Not being strong h. Unable to do anything i. Having less rights

PART 3: What does it mean to be happy? Which of the following are most important to you?

Please rank the following from (1: least important to 5: most important)

20. Hygiene 21. Good/healthy body/physical 22. Healthy mind 23. Having money 24. Sleeping well 25. Having friends 26. Feeling safe PART 4: General feelings in life 1. How often do you feel the following?

Never (0) Sometimes (1) Frequently (2) All the time (3)

27. Angry 28. Regret 29. Upset 30. Lonely 31. Embarrassed 32. Worried 33. Suicidal 34. Unable to sleep 35. Need alcohol 36. Dizziness 37. Afraid/scared 38. Crying 39. Grief/loss

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40. Giving up 41. Overwhelmed 42. Devalued Which of the following statements do you agree with?

Agree Disagree

43. Confident before the disability 44. Confident after the disability PART 5: DASS-21 Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree, or a good part of time 3 Applied to me very much, or most of the time 45. I found it hard to wind down

0 1 2 3

46. I was aware of dryness of my mouth

47. I couldn't seem to experience any positive feeling at all

48. I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)

49. I found it difficult to work up the initiative to do things

50. I tended to over-react to situations

51. I experienced trembling (eg, in the hands)

52. I felt that I was using a lot of nervous energy

53. I was worried about situations in which I might panic and make a fool of myself

54. I felt that I had nothing to look forward to

55. I found myself getting agitated

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PART 6: Impact upon life What are the most significant difficulties you experience since having a disability? (Please choose only 3)

a. Lack of income (if you choose this, answer the questions in BOX 1)

☐

b. Social Relationships (if you choose this, answer the questions in BOX 2)

☐

c. Discrimination (if you choose this, please answer the questions in BOX 3)

☐

d. Expectations (if you chose this, answer the questions in BOX 4)

☐

e. Family Relationships (if you choose this, answer the questions in BOX 5)

☐

BOX 1: How does the lack of income affect you? (Please tick the top 3 multiple choice)

Family Self esteem (status) Services Living standards Discrimination Lack of progress in life Unable to obtain education Social life

BOX 2: Social relationships (please skip this for those who have a congenital disability) Before having a disability my relationships;

Excellent Very good

Good Fair Poor

3. With Friends were

56. I found it difficult to relax

57. I felt down-hearted and blue

58. I was intolerant of anything that kept me from getting on with what I was doing

59. I felt I was close to panic

60. I was unable to become enthusiastic about anything

61. I felt I wasn't worth much as a person

62. I felt that I was rather touchy

63. I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat)

64. I felt scared without any good reason

65. I felt that life was meaningless

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4.With Neighbours were After having a disability my relationships:

3. With Friends are 4. With Neighbours are BOX 3: What kind of discrimination do you experience? (Please tick only 3) ☐ Being blamed ☐ Being teased ☐ People being unfriendly ☐ Bad/swear words ☐ Others being disgusted by disability

Hate from others Lack of respect by others Lack of value by others Others thinking that the disability will transfer to them or other family members

Others encouraging husband/wife to leave the person with a disability Discrimination from siblings

BOX 4: What do you hope for in your future? (Please tick only 3)

Mobility Work Education Marriage Others (please specific): __________

BOX 5:Family (Please tick only 3)

Abuse Being cheated on Depending/reliant on partner Discrimination to family members Divorce Domestic violence

PART 7: Services How often did you receive the service From who did you receive the

service from? 1. How often do you receive the following services? (Please tick the ones that apply)

Never Rarely Sometimes Often NGO DPO CBO SHG GOV

a. Counselling

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b. Physiotherapy c. Material needs

(clothes, books, pens)

d. Travel allowance

e. Livelihood

f. Budget for education

g. Food & shelter

h. Free service

i. Exercise

2 What helps you feel better about life? (Please pick 3 options) a. Encouragement from others/peer support ☐ b. Good relationship ☐ c. Socialising ☐ d. Services/involvement at PRC ☐ e. Religion (meditation/pagoda) ☐

f. Leisure activities ☐

g. Finances/earning an income ☐

h. Assistive devices ☐

i. Awareness against discrimination ☐

Location Please tick all the location of services you receive:

Kampong Cham Chamkar Leu Physical Rehabilitation Centre (PRC)

PART 9: Future Services What services will be most useful for you in the future? (Indicate 5 most important services and rate accordingly)

Very important

Somewhat important

Neutral Somewhat unimportant

Unimportant

Job opportunity/employment services

Counseling

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Mental health services

NGO support for people with disabilities

Home visits Education Medication Social events at

PRC ☐ Getting ID poor cards

Free health careMore health care

facilitiesAssistance with

old ageing☐ Assistive devices (prosthetics, crutches or orthotics)

Awareness raising of rights/needs of people with disabilities

Government support for people with disabilities

Thank you for participating in this survey. END

Appendix 5 People with Disabilities Interview Tool

To be completed by field team members The person completing the form MUST make it clear in the Disability Type category box whether the person has a disability or not. Introduction; The information gathered in this interview will help to understand the mental health of people with disabilities. The information shared in the interview will not be linked to any individual by name. Part 1: Basic Information about the person with a disability/person without a disability Name Optional

Age

Sex Disability Type

Marital Status Married

Roles in the family: Physical Divorced Sensory Women Headed Household Cognitive/Intellectual Widowed

Single

Mental Type of home

No Disability Temporary Permanent Status of the person in the family Health conditions, if so detail Reid Brick

Other Income earner Clay/Sans Unemployed Income Generation Activity (Type)

97

Part 1 a. Whatdoesitmeantobe“apersonwithdisability”? Responses a. Perception before/after (Beggar/dependent/bad luck)

b. Theirroletoyourself,familyandsociety

a. Karma/poverty/stigma/suicide

b. Impactofthesebeliefstoyourself/family/wellbeing

Part 2 a. Howhasdisabilityimpactedyourlife? Responses b. Whatwasitlikebefore/now?

98

c. Levelofindependence/dependence/mobilitylevels/physicalpain

d. Impactonpresentgoals/dreams/worldviews/future/familynorms

Part 3 a. Whathaschanged/whyhasitchanged? Response b. Ability/lifestyle

c. Familystructure/eachrole/responsibilitiesbefore/afterdisability(married/divorce)

d. Livingstandards/income/expenditures/whatwascut

e. Impactonyourself/children/relatives/neighbours/friendships

99

f. Impactfeelingsandwell-being

Basic Needs & Livelihood a. Whatdifficultiesdoyoufaceinthefollowing; Response b. Land/Physicalassetsc. Shelterqualityandfacilitiesd. Ownland/farmingplot/garden

e. Safetyf. Secureenvironment,feelingsofthreat,violence,conflict

g. Food/watera. Gettingenoughfoodforallthemembersofyour/yourself/household?b. Gettingenoughdrinkingandcookingwaterforyourself/allthemembersof

yourhousehold?

h. Livelihood?i. Incomegenerationactivity/work/jobj. Income(money,savings,debts)k. Whatwasitlikebefore/after?l. Effectsonfeelings?m. Impactonwell-beingandfamily?

Educations and Vocational Training

100

a. Howhasyouropportunitieschanged? Response b. Vocationaltraining/job/career

c. Motivation/time/availability?

d. Whatwasitbefore/whataretheynow?

e. Effectonfeelings?

Emotional Well-being Part 1 a. Pleasedescribeyouremotionsasapersonlivingwithadisability? Response b. Sad/happy/lonely/isolated/angry

101

c. Cause/effect

d. Triggers/impact?

e. SuicideIdeation

Emotional Well-being Part 2 f. Canyoudescribehowthefollowingaffectsyouremotionsandviceversa? Response g. Family/neighbors/community

h. Studies/work/sociallife

i. Poverty/discrimination/government

Emotional Well-being Part 3

102

j. Whatdoescounselling/encouragementlooklike? Response k. Who/why/how/whatissaid?

l. Howeffective?

m. Theimpact?

Community Social and Civic Life Part 1 a. Howhasyourcommunitylifebeenaffected? Response b. AttendingSHGs/DPO/DistrictFederations

c. Attendingceremoniessuchasmarriages,funeralsorinitiationceremonies

103

d. Attitudes/beliefs/expectationsregardingthecommunity?

e. Whatwasitlikebefore/whathaschanged?

f. Howdoesthisimpactyourfeelings,well-beingandyourfamily?

Community Social and Civic Life Part 2 g. Howhasdiscriminationimpactyouandyourfamily? Response h. Poverty/gender/disability/religion/culturalnorms?

i. Personwithdisability,you,family

j. Whatwasitlikebefore/whathaschanged?

104

k. Howdoesthisimpactyourwell-beingandyourfamily?

Community Social and Civic Life Part 3 l. Whatdoesitmeanforyouandyourfamilytobeincluded? Response m. Invitations/beinginformed/beingtreatedasnormal

n. Whatwasitlikebefore/whatchanged?

o. Howdoesthisimpactyourfeelings,well-beingandyourfamily?

Support and Relationships a. Howhaveyoursocialrelationshipsbeenaffected? Response b. Who?Socialnetworks/workcolleagues/

105

c. Whatwaslikeitbefore/whatchanged?

d. Howdoesthisimpactyourfeelings,well-beingandyourfamily?

Recognition, respect, being heard a. Howhasyoursenseof“selfvalue”changedasaresultofadisability? Response b. One’srights/respect/opinions/valueinsociety

c. Whatwaslikeitbefore/whatchanged?

d. Howdoesthisimpactyourfeelings,well-beingandyourfamily?

Services and Accessibility Part 1 a. What are the difficulties you face in in the following? Response

106

b. PhysicalAccessibilitya. Movinginto&outofyourhomeb. Movingaroundyourhomec. Usingareasofyourhome,toilet,kitchen,bedroom

c. InformationAccessa. Healthcareinformationb. Leafletsonserviceinformationc. Equityfundinformationd. IDPoorCard

d. Howdoesthisimpactyourfeelings,well-beingandyourfamily?

Services and Accessibility Part 2 e. What services are you accessing? Response f. Medication/Physiotherapy/Counselling?

g. Howdidyoufindout/whoinformedyou/why?

h. Facilitators/barriers?

107

i. Why/how long/who?

j. Effective/ineffective?(Good/bad/helpful/unhelpful)

k. Strengths/weakness/what’smissing?

l. Impact on family?

Services and Accessibility Part 2 m. Whataretheimpactsofneedingtoaccessservices? Response n. Needingacarer/needbudgetfortravelling?

o. Effectincomeopportunity/expenditures?

108

p. Effectsonfamily/anydependentsathome?

q. Expectedimpactonwell-beingandfamily?

Services and Accessibility Part 3 r. Whatarethebestwaystosupportpeoplewithdisabilities? Response s. Psychologicaldistress/mentalhealth/generalhealth

t. Accessibility/inclusion/anti-discrimination/trainingondisability

u. Financialassistance/emotionalsupport

v. Exceptedimpactonwell-beingandfamily?

109

Appendix 6

Family and Carers of People with Disabilities Interview Tool To be completed by field team members The person completing the form MUST make it clear in the Disability Type category box whether the person has a disability or not. Introduction; The information gathered in this interview will help to understand the mental health of people with disabilities. The information shared in the interview will not be linked to any individual by name. Part 1: Basic Information about the person with a disability/person without a disability Name Optional

Age

Sex Disability Type

Marital Status Married

Roles in the family: Physical Divorced Sensory Women Headed Household Cognitive/Intellectual Widowed

Single

Mental Type of home

No Disability Temporary Permanent Status of the person in the family Health conditions, if so detail Reid Brick

Other Income earner Clay/Sans Unemployed Income Generation Activity (Type)

110

Part 1 b. Whatdoesitmeantohave“apersonwithdisability”inthefamily? Responses c. Perception before/after (Beggar/dependent/bad luck)

d. Theirroletoyourself,familyandsociety

c. Karma/poverty/stigma/suicide

d. Impactofthesebeliefstoyourself/family/wellbeing

Part 2 e. Whatareyourexperienceslivingwith“apersonwithdisability”? Responses f. Feelings,negative/positiveexperiences

111

e. Impacttoyourself,familyandcommunity

f. Impactonpresentgoals/dreams/worldviews/future/familynorms

Part 3 g. Whathaschanged/whyhasitchanged? Response g. Familystructure/eachrole/responsibilitiesbefore/afterdisability

(married/divorce)

a. Livingstandards/income/expenditures/whatwascut

b. Impactonyourself/children/relatives/neighbours/friendships

c. Impactfeelingsandwell-being

112

Basic Needs & Livelihood n. Whatdifficultiesdoyoufaceinthefollowing; Response o. Land/Physicalassetsp. Shelterqualityandfacilitiesq. Ownland/farmingplot/garden

r. Safetys. Secureenvironment,feelingsofthreat,violence,conflict

t. Food/waterc. Gettingenoughfoodforallthemembersofyour/yourself/household?d. Gettingenoughdrinkingandcookingwaterforyourself/allthemembersof

yourhousehold?

u. Livelihood?v. Incomegenerationactivity/work/jobw. Income(money,savings,debts)x. Whatwasitlikebefore/after?y. Effectsonfeelings?z. Impactonwell-beingandfamily?

Educations and Vocational Training f. Howhasyouropportunitieschanged? Response g. Vocationaltraining/job/career

113

h. Motivation/time/availability?

i. Whatwasitbefore/whataretheynow?

j. Effectonfeelings?

Emotional Well-being Part 1 n. Pleasedescribetheemotionsyoufeelasaresultofcaringforsomeonewitha

disability?Response

o. Sad/happy/lonely/isolated/angry

p. Cause/effect

q. Triggers/impact?

114

r. SuicideIdeation?

Emotional Well-being Part 2 s. Canyoudescribehowthefollowingaffectsyouremotionsandviceversa? Response t. Family/neighbors/community

u. Studies/work/sociallife

v. Poverty/discrimination/government

Emotional Well-being Part 3 w. Whatdoescounselling/encouragementlooklike? Response x. Who/why/how/whatissaid?

115

y. Howeffective?

z. Theimpact?

Community Social and Civic Life Part 1 p. Howhasyourcommunitylifebeenaffected? Response q. Socialevents/attending/beingpartofsupportgroupssuchasParentGroups,

Women’sGroups,andSocialGroups.

r. Attitudes/beliefs/expectationsregardingthecommunity?

s. Whatwasitlikebefore/whathaschanged?

t. Howdoesthisimpactyourfeelings,well-beingandyourfamily?

116

Community Social and Civic Life Part 2 u. Howhasdiscriminationimpactyouandyourfamily? Response v. Poverty/gender/disability/religion/culturalnorms?

w. Personwithdisability,you,family

x. Whatwasitlikebefore/whathaschanged?

y. Howdoesthisimpactyourwell-beingandyourfamily?

Community Social and Civic Life Part 3 z. Whatdoesitmeanforyouandyourfamilytobeincluded? Response aa. Invitations/beinginformed/beingtreatedasnormal

117

bb. Whatwasitlikebefore/whatchanged?

cc. Howdoesthisimpactyourfeelings,well-beingandyourfamily?

Support and Relationships e. Howhaveyoursocialrelationshipsbeenaffected? Response f. Who?Socialnetworks/workcolleagues/

g. Whatwaslikeitbefore/whatchanged?

h. Howdoesthisimpactyourfeelings,well-beingandyourfamily?

Recognition, respect, being heard e. Howhasyoursenseof“selfvalue”changedasaresultofcaringforsomeone

withadisability?Response

118

f. One’srights/respect/opinions/valueinsociety

g. Whatwaslikeitbefore/whatchanged?

h. Howdoesthisimpactyourfeelings,well-beingandyourfamily?

Services and Accessibility Part 1 w. What services do you help the person with disability access? Response x. Medication/Physiotherapy/Counselling?

y. Howdidyoufindout/whoinformedyou/why?

z. Facilitators/barriers?

119

aa. Why/how long/who?

bb. Effective/ineffective?(Good/bad/helpful/unhelpful)

cc. Strengths/weakness/what’smissing?

dd. Impact on family?

Services and Accessibility Part 2 ee. Whataretheimpactsofneedingtoaccessservices? Response ff. Needingacarer/needbudgetfortravelling?

gg. Effectincomeopportunity/expenditures?

120

hh. Effectsonfamily/anydependentsathome?

ii. Expectedimpactonwell-beingandfamily?

Services and Accessibility Part 3 jj. Whatarethebestwaystosupportpeoplewithdisabilities? Response kk. Psychologicaldistress/mentalhealth/generalhealth

ll. Accessibility/inclusion/anti-discrimination/trainingondisability

mm. Financialassistance/emotionalsupport

nn. Exceptedimpactonwell-beingandfamily?

121

Appendix 7

Community Member Interview Tool To be completed by field team members Introduction; The information gathered in this interview will help to understand the mental health of people with disabilities. The information shared in the interview will not be linked to any individual by name. Part 1: Basic Information about the community member

Key Informants Frame

Thistoolistobecompletedbythefieldteammembertorecorddiscussions. Introduction; The information gathered in this group will help to understand the mental health of people with disabilities. The information shared in the interview will not be linked to any individual by name.

NAME(FIRST,LAST) GENDER AGE TIME IN ROLE POSITION DATE LOCATION Other

Please detail

122

Disability Part 1 c. What does it mean for someone to have a “disability”? Responses d. The individual, family and society

e. Perceptionbefore/after(Beggar/dependent/badluck)

f. Karma/poverty/stigma/suicide

g. Belonging/future/role

Disability Part 2 h. What are your experiences of having someone with “a person with disability” in the

community? Responses

i. Attitudes/beliefs/expectations/perceptions

123

j. Feelings,negative/positiveexperiences

k. Comparedtopeoplewithoutdisabilities?

Disability Part 3 l. Whatchangesdoyouthinktheyexperienceinthefamilyandwhy? Response

m. Familystructure/eachrole/responsibilitiesbefore/afterdisability(married/divorce)

n. Livingstandards/income/expenditures/whatwascut

o. Impactonchildren/relatives/neighbors/friendships

p. Impactfeelingsandwell-being

124

Basic Needs & Livelihood aa. Whatdifficultiesdoyouthinkpeoplewithdisabilitiesandtheirfamiliesfacein

thefollowing?Response

bb. Land/Physicalassetscc. Shelterqualityandfacilitiesdd. Ownland/farmingplot/garden

ee. Safetyff. Secureenvironment,feelingsofthreat,violence,conflict

gg. Food/watere. Gettingenoughfoodforallthemembersofyour/yourself/household?f. Gettingenoughdrinkingandcookingwaterforyourself/allthemembersof

yourhousehold?

hh. Livelihood?ii. Incomegenerationactivity/work/jobjj. Income(money,savings,debts)kk. Whatwasitlikebefore/after?ll. Effectsonfeelings?mm. Impactonwell-beingandfamily?

Support and Relationships i. Howdoyouthinktheirsocialrelationshipswillhavebeenaffected? Response

125

j. Who?Socialnetworks/workcolleagues/community/

k. Whatwaslikeitbefore/afterdisability?

l. Whatwouldhavechanged?Why?

m. Effectsonfeelings

Educations and Vocational Training k. Howhastheiropportunitieschanged? Response l. Vocationaltraining/job/career

126

m. Motivation/time/availability?

n. Effectonfeelings?

Emotional Well-being Part 1 aa. Whatemotionsdoyouthinkpeoplewithdisabilitiesfeelasaresultofa

disability?Response

bb. Annoyed/impatient/inexperienced/unsure/scared/hopeless/sad

cc. Why?(poverty/lackofcapacity/abuse)

dd. Cause/effect

127

ee. Triggers/impactonfamily/community?

ff. SuicideIdeation?

Emotional Well-being Part 2 gg. Howdoyouthinkthefollowingaffectstheemotionsofanindividualwhohasa

disabilityandviceversa?Response

hh. Family/neighbors/communitya. Seeingothersprogressb. Unabletoborrowmoney/lackcapitalc. Unabletosendchildrentoschool

ii. Studies/work/sociallife

jj. Poverty/discrimination/government

kk. Gender/disability/religion/culturalnorms

Emotional Well-being Part 3

128

ll. Whatdoesemotionalsupportlooklikeforapersonwithdisabilities? Response mm. Who/why/how/whatissaid?nn. medicine/encouragement/counselling/doctors/empathy

oo. Howeffective?

pp. Theexpectedimpact?

Community Social and Civic Life Part 1 dd. Whatdifficultiesdopeoplewithdisabilitiesexperiencewhentryingtobe

involvedinthecommunity?Response

ee. Socialevents/attending/beingpartofsupportgroupssuchasParentGroups,Women’sGroups,andSocialGroups.

ff. Lackofaccess/discrimination/lackofmoney/lackoftime/fear

129

gg. Attitudes/beliefs/expectationsregardingthecommunity?

hh. Comparedtosomeonewithoutadisability?

ii. Howdoesthisimpacttheirfeelings,well-beingandtheirfamily?

Community Social and Civic Life Part 2 jj. Whatsupportareyoucurrentlyprovidingforpeoplewithdisabilitieswithin

yourcommunity?Response

kk. Upskilling/donations/encouragement/materialgoods

ll. Facilitators/barriers/challenges

mm. Why/how long/who?

130

nn. Impact on person with disability/family/community?

Community Social and Civic Life Part 3 oo. Howthecommunitydealwithdiscrimination? Response pp. Poverty/gender/disability/religion/culturalnorms/personwith

disability/family

qq. Why/how/when/who

rr. Howdoesthisimpacttheirfeelings,well-beingandtheirfamily?

Community Social and Civic Life Part 4 ss. Howthecommunitydealwithabuseanddomesticviolence? Response tt. Personwithdisabilityandtheirpartners/children/parents

131

uu. Reporting/responding/advising/responsibility

vv. Suicide/suicidecontemplation

ww. Impactonfamilyandcommunity

Community Social and Civic Life Part 5 xx. Whatdoesitmeantobeincludedinthecommunity? Response yy. Invitations/beinginformed/beingtreatedasnormal

zz. Whatwasitlikebeforedisability/whatchangedandwhy?

aaa. Howdoesthisimpactindividuals,familiesandthesociety?

132

Community Social and Civic Life Part 6 bbb. Whatarethebestwaystosupportpeoplewithdisabilities? Response ccc. Homevisits/conductfundraisersinthecommunity/talking

ddd. Accessibility/inclusion/anti-discrimination/training

eee. Who/when/how/where/why

fff. Howdoesthisimpactindividuals,familiesandthesociety?

n. Whatwaslikeitbefore/whathaschanged?

o. Howdoesthisimpacttheirfeelings,well-beingandtheirfamily?

Community Social and Civic Life Part 7

133

p. Howcanthecommunityplayaroleinincreasingthesenseofrespect/recognitionforsomeonewithadisability?

Response

q. One’srights/respect/opinions/valueinsociety

r. Individualwithdisability/family/community

s. Effectsonfeelings

134

Appendix 8

Service Providers Interview Tool To be completed by field team members Introduction; The information gathered in this interview will help to understand the mental health of people with disabilities. The information shared in the interview will not be linked to any individual by name. Part 1: Basic Information about the service provider

Key Informants Frame

Thistoolistobecompletedbythefieldteammembertorecorddiscussions. Introduction; The information gathered in this group will help to understand the mental health of people with disabilities. The information shared in the interview will not be linked to any individual by name.

NAME(FIRST,LAST) GENDER AGE TIME IN ROLE POSITION DATE LOCATION Other

Please detail

135

Disability Part 1 h. What does it mean for someone to have a “disability”? Responses i. The individual, family and society

j. Perceptionbefore/after(Beggar/dependent/badluck)

k. Karma/poverty/stigma/suicide

l. Belonging/future/role

Disability Part 2 q. What are your experiences of working with “a person with disability”? Responses r. Attitudes/beliefs/expectations/perceptions

136

s. Feelings,negative/positiveexperiences

t. Comparedtopeoplewithoutdisabilities?

Disability Part 3 u. Whatchangesdoyouthinktheyexperienceinthefamilyandwhy? Response

v. Familystructure/eachrole/responsibilitiesbefore/afterdisability(married/divorce)

w. Livingstandards/income/expenditures/whatwascut

x. Impactonchildren/relatives/neighbours/friendships

y. Impactfeelingsandwell-being

137

Basic Needs & Livelihood nn. Whatdifficultiesdoyouthinkpeoplewithdisabilitiesandtheirfamiliesfacein

thefollowing?Response

oo. Land/Physicalassetspp. Shelterqualityandfacilitiesqq. Ownland/farmingplot/garden

rr. Safetyss. Secureenvironment,feelingsofthreat,violence,conflict

tt. Food/waterg. Gettingenoughfoodforallthemembersofyour/yourself/household?h. Gettingenoughdrinkingandcookingwaterforyourself/allthemembersof

yourhousehold?

uu. Livelihood?vv. Incomegenerationactivity/work/jobww. Income(money,savings,debts)xx. Whatwasitlikebefore/after?yy. Effectsonfeelings?zz. Impactonwell-beingandfamily?

Support and Relationships t. Howdoyouthinktheirsocialrelationshipswillhavebeenaffected? Response

138

u. Who?Socialnetworks/workcolleagues/community/

v. Whatwaslikeitbefore/afterdisability?

w. Whatwouldhavechanged?Why?

x. Effectonfeelings?

Educations and Vocational Training o. Howhastheiropportunitieschanged? Response p. Vocationaltraining/job/career

139

q. Motivation/time/availability?

r. Effectonfeelings?

Emotional Well-being Part 1 qq. Whatemotionsdoyouthinkpeoplewithdisabilitiesfeelasaresultofa

disability?Response

rr. Annoyed/impatient/inexperienced/unsure/scared/hopeless/sad

ss. Why?(poverty/lackofcapacity/abuse)

tt. Cause/effect

140

uu. Triggers/impactonfamily/community?

vv. SuicideIdeation?

Emotional Well-being Part 2 ww. Howdoyouthinkthefollowingaffectstheemotionsofanindividualwhohasa

disabilityandviceversa?Response

xx. Family/neighbors/communitya. Seeingothersprogressb. Unabletoborrowmoney/lackcapitalc. Unabletosendchildrentoschool

yy. Studies/work/sociallife

zz. Poverty/discrimination/government

aaa. Gender/disability/religion/culturalnorms

Emotional Well-being Part 3

141

bbb. Whatdoesemotionalsupportlooklikeforapersonwithdisabilities? Response ccc. Who/why/how/whatissaid?ddd. medicine/encouragement/counselling/doctors/empathy

eee. Howeffective?

fff. Theexpectedimpact?

Service and Accessibility Part 1 ggg. Whatarethedifficultiesthatpeoplewithimpairmentsfaceintermsof: Response hhh. InformationAccess

d. Healthcareinformatione. Leafletsonserviceinformationf. Equityfundinformationg. IDPoorCard

Service and Accessibility Part 2 iii. Whatservicesareyouprovidingforpeoplewithdisabilities? Response jjj. Health/mentalhealth/physiotherapy

142

kkk. Facilitators/barriers/challenges

lll. Why/how long/who?

mmm. Impact on person with disability/family/community?

Service and Accessibility Part 3 nnn. Whatchallengesdopeoplewithdisabilitiesexperiencewhenaccessing

theseservices?Response

ooo.Discrimination/lackofinformation

ppp. Needingacarer/needbudgetfortravelling?

143

qqq. Effectincomeopportunity/expenditures?

rrr. Effectsonfamily/anydependentsathome?

sss. Expectedimpactonwell-beingandfamily?

Service and Accessibility Part 4 ttt. Whatarethebestwaystosupportpeoplewithdisabilities? Response uuu. Psychologicaldistress/mentalhealth/generalhealth

vvv. Accessibility/inclusion/anti-discrimination/trainingondisability

www. Suicide/suicidecontemplation

144

xxx. Collaboratewithhospitalstocheckaccessibility

Service and Accessibility Part 5 yyy. Howcanserviceprovidersplayaroleinincreasingthesenseof

respect/recognitionforsomeonewithadisability?Response

zzz. One’srights/respect/opinions/valueinsociety

aaaa. Individualwithdisability/family/community

bbbb. Effectsonfeelings

7.Listofpersonsmetduringthestudyprocessandsalientpointsofthemeetings

146

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