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African Journal of Disability (Online)
Afr. j. disabil. (Online) vol.6 Durbanville 2017
http://dx.doi.org/10.4102/ajod.v6i0.318
Wheelchair services and use outcomes: A cross-sectional survey in Kenya and the Philippines
Eva S. BazantI; Elizabeth J. Himelfarb HurwitzI; Brenda N. OngutiII; Emma K. WilliamsI; Jamie H. NoonIII; Cheryl A. XavierIV; Ferdiliza D.S. GarciaV; Anthony GichangiII; Mohammed GabbowVI; Peter MusakhiVII; R. Lee KirbyVIII
IJhpiego, Baltimore, United States
IIJhpiego, Nairobi, Kenya
IIINoon Design, Cerrillos, United States
IVPrivate Sector, Matale, Sri Lanka
VCollege of Allied Medical Professions, University of the Philippines, Manila, Philippines
VINational Council for Persons With Disabilities, Government of Kenya, Kenya
VIIMinistry of East African Community (EAC), Labour and Social Protection, Government of Kenya, Kenya
VIIIDivision of Physical Medicine & Rehabilitation, Dalhousie University, Canada
BACKGROUND: The World Health Organisation recommends that services accompany wheelchair distribution. This study examined the relationship of wheelchair service provision in Kenya and the Philippines and wheelchair-use-related outcomes.
METHOD: We surveyed 852 adult basic manual wheelchair users. Participants who had received services and those who had not were sought in equal numbers from wheelchair-distribution entities. Outcomes assessed were daily wheelchair use, falls, unassisted outdoor use and performance of activities of daily living (ADL). Descriptive, bivariate and multivariable regression model results are presented.
RESULTS: Conditions that led to the need for a basic wheelchair were mainly spinal cord injury, polio/post-polio, and congenital conditions. Most Kenyans reported high daily wheelchair use (60%) and ADL performance (80%), while these practices were less frequent in the Philippine sample (42% and 74%, respectively). Having the wheelchair fit assessed while the user propelled the wheelchair was associated with greater odds of high ADL performance in Kenya (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.6, 5.1) and the Philippines (OR 2.8, 95% CI 1.8, 4.5). Wheelchair-related training was associated with high ADL performance in Kenya (OR 3.2, 95% CI 1.3, 8.4). In the Philippines, training was associated with greater odds of high versus no daily wheelchair use but also odds of serious versus no falls (OR 2.5, 95% CI 1.4, 4.5.
CONCLUSION: Select services that were associated with some better wheelchair use outcomes and should be emphasised in service delivery. Service providers should be aware that increased mobility may lead to serious falls.
An estimated 20 million people worldwide in 2003 needed a wheelchair for mobility and lacked one (World Health Organization [WHO] 2008). In less resourced settings, access to appropriate wheelchairs is limited. An appropriate wheelchair allows the user to meet his or her mobility needs in the local environment, providing postural support with proper fit and is durable, safe, available, affordable and maintainable by the user (WHO 2008). Globally, charitable, governmental and service organisations provide wheelchairs. However, users in less resourced settings often receive inappropriate wheelchairs or wheelchairs with inadequate services. Awareness is increasing wheelchair provision by trained personnel increases the chance that wheelchair users receive appropriate wheelchairs (Toro, Eke & Pearlman 2016).
The WHO Guidelines on the Provision of Manual Wheelchairs in Less Resourced Settings calls for the components of wheelchair service delivery to include referral and appointment, assessment, prescription (selection), funding and ordering, product preparation, fitting, user training, follow-up, maintenance and repairs (WHO 2008). Few studies have assessed whether users in less resourced settings have received these services and user outcomes (Borg et al. 2012; Greer, Brasure & Wilt 2012; Toro et al. 2016).
Lack of service provision may be one of the reasons for wheelchair abandonment. In 2005 in West Bengal, India, over half of 162 hand rim-propelled manual wheelchairs distributed to individuals with lower-limb dysfunction went unused because of pain, fatigue, discomfort and lack of habitat adaptability (Mukherjee & Samanta 2005). It is not known if the users who abandoned these wheelchairs had received any supportive services.
Wheelchairs need to be rugged to withstand use in challenging terrain (Rispin &Wee 2014). In Nepal, two-thirds of donated standard wheelchairs in one study needed replacement within two years, leaving users unable to access the community independently (Scovil et al. 2012). Even in the United States, about half of wheelchairs need repair within six months of issue (Worobey et al. 2012).
User involvement in wheelchair selection has seen positive effects. In Bangladesh, measuring a user for a wheelchair increased the likelihood of wheelchair satisfaction, and wheelchair training was associated with the user reporting fewer activity limitations and participation restrictions (Borg et al. 2012). The effectiveness of wheelchair skills training is well documented (for instance Best et al. 2005, 2016; Kirby et al. 2016a; MacPhee et al. 2004; Ozturk & Ucsular 2011; Routhier et al. 2012; Worobey et al. 2016; Tu et al. 2017). However, greater wheelchair use in varied terrain can lead to falls and injury (Berg, Hines & Allen 2002; Calder & Kirby 1990; Gaal et al. 1997; Kirby et al. 1994; Nelson et al. 2010; Xiang, Chany & Smith 2006).
The objective of this study was to examine whether wheelchair service receipt is associated with successful wheelchair use among adult, basic manual wheelchair users in less resourced settings. The hypothesis was that wheelchair service receipt is associated with high daily wheelchair use, independent outdoor mobility and high performance of activities of daily living (ADL) and with fewer reports of serious falls.
Research methods and design
Design and locations
This was a cross-sectional survey of wheelchair users in Kenya and the Philippines. The two-country study was done in sub-Saharan Africa and Asia at the request of the funder. Wheelchair sector stakeholders advised the research team on the study location. Priority was placed on countries with high wheelchair distribution, countries with organisations providing wheelchair services and a country where the institution of the lead author of this article had an office. In each country, investigators met with stakeholders in the field of disability and wheelchairs to discuss the study purpose and methods.
Dissemination of information about the study to organisations, sampling and recruitment
We aimed to enrol a sample that would be composed equally of participants who had received services with the current wheelchair and those who did not.
Eligible wheelchair users were age 18 or older, did not require postural support and those who received their current or most recently acquired wheelchair within the past five years but greater than three months before the survey date to ensure experience with the current chair. Exclusion criteria were being a temporary wheelchair user or a user of an arm-crank-propelled tricycle, inability to communicate in either English, Swahili in Kenya or Filipino in the Philippines; or inability to understand the questions. In the Philippines, it was difficult to find users who had received services. In the last month of data collection, the study protocol was amended to include wheelchair users who had received the current wheelchair in the last 10 years.
The screening question to potential participants was: 'When you received your current or most recent chair, did a wheelchair provider help you choose the right wheelchair? The provider might have measured your body, checked the fit of the wheelchair, or made adjustments to the wheelchair.'
In Kenya, residents of urban and peri-urban areas were sampled from lists provided by wheelchair-providing organisations that were faith-based, non-governmental, community-based, related to disabled person's rights or government hospitals and schools. In the Philippines, Greater Manila residents were sampled through lists of wheelchair users provided by five local government units that provided wheelchairs to citizens, a wheelchair charity and a non-governmental organisation that employed wheelchair users. In addition, in both countries, snowball sampling occurred, in which study participants referred members of their personal networks. Participants and up to one caregiver received locally appropriate participation and travel reimbursements in the Philippines. In Kenya, local investigators considered reimbursement inappropriate and it was not given in Kenya, per the study protocol and this was approved by the ethical review boards.
The sample size calculation was specified to detect a difference of 15% points on the primary outcome of high daily wheelchair use between wheelchair users who reported receiving services with the current chair and those who did not. The hypothesis was that the outcome would be 50% among those in the service group, a percentage that would yield the largest and most conservative sample size. The power was set at 80%, alpha level of significance was set at 0.05 and intra-cluster correlation was set at 0.002. The sample size calculation called for 500 per country with 10 clusters or groupings.
Data collection and management
Data collection occurred from December 2014 to June 2015 in Kenya and from February to May 2015 in the Philippines. In Kenya, the authors' institutional staff collected data. In the Philippines, a local organisation with experience in disability sector research was selected through a competitive process. Data collection was conducted by 8 surveyors and 4 field supervisors in Kenya and 15 surveyors and 7 field supervisors in the Philippines. Surveyors had secondary education and data collection experience in the Philippines and college/university education in Kenya. In each country, surveyors received one week of training on data collection procedures, including use of the instruments, informed consent and research ethics.
The paper-based tool was digitised using Open Data Kit (https://opendatakit.org/ and Brunette et al. 2013) and collected on Android tablet computers in each country. Data were exported to a Microsoft Excel 2013 database. Data cleaning was conducted in Kenya using Excel and in the Philippines in IBM Statistical Product and Service Solutions version 20 for Windows (Armonk, NY, 2011). This step was to ensure that study identification numbers for the participants were captured correctly and were not repeated and that snowballed participants were assigned to the index participant's cluster for analysis.
The development of the survey instrument occurred in phases. Firstly, the investigators sought out published instruments and 22 instruments were found. Secondly, the content of the questions in the instruments was reviewed for the main themes and sub-themes. Many of the existing instruments were not considered to be readily adaptable to the setting and research questions of this study within the time frame of the project. Some questions used in the survey were informed by the existing instruments. These instruments include the Wheelchair Adapted International Outcome Inventory for Hearing Aids (Borg et al. 2012); the Wheelchair Skills Test Questionnaire (Kirby et al. 2016b); the Wheelchair Use Confidence Scale for Manual Wheelchair Users (Version 3.0) (Rushton et al. 2013); the Efficiency of Assistive Technology and Services 6D Forms (Andrich et al. 1998); and Life Space Assessment (Peel et al. 2005). Throughout the process, wheelchair stakeholders advised on the survey instrument development.
Thirdly, this study developed a conceptual framework to guide measurement (Figure 1-A1; Accelovate 2015). It was informed by two main published frameworks, a framework of public health intervention researchers (Bryce et al. 2011) and the wheeled mobility framework of Routhier et al. (2003). The study framework covered the environmental context and actors and programme inputs, outputs, outcomes and impact.
Fourthly, pilot testing of the instrument occurred during field visits in April 2014 in Manila, Philippines, and May 2014 in Dar es Salaam and Moshi, Tanzania, possible locations for the study (Figure 2-A1; Accelovate 2015). Investigators met with organisations providing wheelchairs and services. The draft survey instrument was discussed with wheelchair organisation stakeholders and through a focus group with wheelchair users to discuss the instrument and gather feedback on the relevance of questions to their lives. After the field visits, the survey instrument questions were refined.
The survey instrument asked about past receipt of the steps of wheelchair service recommended by WHO considered most amenable to self-reporting: assessment, fitting, training and maintenance, repair and follow-up (WHO 2008). The survey's questions were related to sociodemographic and other personal characteristics, the experience and receipt of wheelchair services with the current wheelchair or any wheelchair ever received during the lifetime. The survey questions were also related to the wheelchair characteristics and acquisition. Lastly, the questions inquired about the outputs of daily wheelchair use and experience of severe falls and the outcomes of high performance of ADL and unassisted outdoor mobility. The survey instrument was translated into Swahili in Kenya and Filipino in the Philippines and back-translated to English.
Variables and analysis
We collected sociodemographic, clinical and wheelchair data, specifically age, gender, county (in Kenya), educational level, marital status, employment type, wealth quintile, condition that led the user to need a wheelchair, number of wheelchairs acquired in last five years, source of wheelchair and whether or not the wheelchair was donated or received at no cost to the user. The question on the type of wheelchair had response categories of 'basic indoor chair', 'rough terrain wheelchair with long wheel-base', 'wheelchair unavailable' and 'don't know'. Household wealth was based on a module of standard questions from large household surveys (Kenya National Bureau of Statistics and ICF Macro 2010).
The survey asked whether the user received one of many services with the current wheelchair, as well as services ever received during the participant's lifetime. In the analysis, the answer of 'yes' to several questions was used to create a composite or summary variable to describe assessment, fitting and training. Maintenance, repair, follow-up and other services were assessed in a single item. Details on creation of the service variables are presented in Table 1-A1.
To measure the output of daily wheelchair use, participants were asked how long they used or occupied their wheelchairs from the time they woke up to midday and from midday to the time of going to bed, to arrive at the total number of hours. Responses were categorised as 'not daily', '1-7 hours daily' and '≥ 8 hours daily'. This was based on the distribution of responses to the continuous variable.
To measure the output of falls, the survey asked, 'With your current wheelchair have you ever fallen?'. The next question was 'Was this a serious fall? By serious, I mean a fall that left you with pain or soreness that lasted more than one hour, bruising, skin cuts or abrasions, or injuries to your bones or joints'. This variable was analysed as a three-level variable of 'no falls', 'non-serious falls' and 'serious falls'.
To measure the outcome of unassisted outdoor mobility, three survey questions were used. Users were coded as 'yes' on this outcome if they reached an area outside their home in a wheelchair in the last month and did not need help in doing so. Those who did not have another area to go to were excluded. Those who reached another area but not in a wheelchair were coded 'no'.
To measure the outcome of high performance of ADL, participants were told, 'For each activity that I read, please let me know if you perform it independently or assisted'. Items were bathing, dressing, eating and toilet hygiene. Response categories were 'Independently' and 'Assisted'. If the activity was performed independently or unassisted, this variable was coded 1 and if not, 0. Performance was considered 'high' if at least three of the four items were carried out unassisted and 'low' for zero-two items.
Analysis was carried out for each country separately and data were not combined across countries because of differences in sampling strategies and geographic coverage. Descriptive results are frequencies and tabulations. In bivariate analysis, each wheelchair service variable was assessed for its association with the output or outcome. Logistic regression was used for dichotomous variables yielding odds ratios (ORs). Multinomial logistic regression was used for three-level outcomes. These models produce relative risk ratios, which can be interpreted as ORs. The models accounted for within-cluster correlation of outcomes (Rogers 1993) using the 'vce(cluster)' option in Stata software (StataCorp 2013). In Kenya, the organisation from which the investigators received the contact information of the wheelchair users was designated the cluster. In Philippines, a neighbourhood unit called a barangay within the local government unit from which we received the contact information of the wheelchair users was designated the cluster. In both countries, 'snowballed' wheelchair users who were referred by another participant to the survey team were assigned the cluster of the index participant.
To answer the research questions, wheelchair service items as well as participants' sociodemographic or wheelchair user variables significantly associated with wheelchair use outputs and outcomes at p < 0.10 in the bivariate analyses were entered into multivariable models. Multivariable regression models controlled for potential confounders of the relationship of wheelchair services and wheelchair outputs or outcomes.
Models in Kenya were adjusted for number of wheelchairs acquired in the last five years, county, age category, educational level, marital status, employment type, condition that led the user to need a wheelchair, source of wheelchair, wealth quintile, whether or not the wheelchair was donated and type of wheelchair. Models in Philippines were adjusted for number of wheelchairs acquired in last five years, region, age category, educational level, gender, condition that led user to need a wheelchair, any employment, source of wheelchair, and whether or not the wheelchair was donated. Models for performance for ADL and falls were also adjusted for the three-level daily wheelchair use level.
A few variables had some missing data. In Kenya, between 10 and 12 respondents were missing data for age and marital status. In the Philippines, the source of the wheelchair was missing for 10 respondents and for 'current wheelchair donated', 13 are missing. For 'current wheelchair has a cushion', the interviewer was unable to record this information for 60 respondents in Kenya and 5 respondents in the Philippines. Wheelchair services significantly associated with each outcome were identified by the 95% confidence interval (CI) of the adjusted ORs that did not cross 1.0. All analyses were conducted in Stata 13.0 (StataCorp, College Station, TX).
This study received ethical approval from the institutional review boards of Johns Hopkins University Bloomberg School of Public Health in Baltimore, MD, United States (#5839); Kenya Medical Research Institute in Nairobi, Kenya (Non-SSC Determination #457); and University of Philippines Manila Research Ethics Board (#2014-351-01). All study participants provided informed consent immediately prior to the survey participation. Consent was oral in Kenya, according to an approved consent script. At the request of the University of Philippines, consent included participant signature. Interviews were carried out in spaces allowing for audio and visual privacy.
Samples achieved
In Kenya, after removing duplicate names from a list of 1764 wheelchair users, potentially eligible participants were 1612; of these participants, 671 could not be reached. Of the 941 participants screened, 512 were eligible and 429 ineligible. Of the eligible, 72 participants were unavailable. In Kenya, 440 participants were included. Twenty participants were younger than age 18 according to the birthdate in the survey and their data were not analysed, yielding 420 participants whose data were analysed.
In the Philippines, of the 1490 wheelchair user names, 575 potential participants could not be screened because they were inaccessible by phone or because they had died. Of the 915 participants reached and screened, 497 were eligible and 417 ineligible because they used a non-basic wheelchair, they were younger than age 18, were unable to communicate or had received current wheelchair more than five years ago. However, this criterion was relaxed in the last month of survey data collection to reach enrolment goals. In the Philippines, 56 participants were unavailable and 9 declined. Overall, 432 participants were included. Figure 3-A1 depicts the locations of the study participants in each country.
Descriptive results
Sample characteristics
In Kenya, participants were primarily men, younger than age 50 and employed (Table 1). The most commonly reported conditions requiring the need for wheelchairs were spinal cord injury, polio or post-polio and congenital issues. The most common sources of the current wheelchairs were charity, government and family or friend. Current wheelchair types were basic indoor wheelchairs for the majority of the sample, while others had rough-terrain wheelchairs or unknown types. For 54% of participants, the current wheelchairs had a cushion at the time of the interview.
In the Philippines, participants were about equally split by gender, mostly age 50 or older and unemployed, and nearly half were married or cohabiting. Conditions related to the need for wheelchairs included old age, arthritis and bone problems; polio or post-polio and spinal cord injury plus old age or arthritis or bone problems, and stroke, nerve- or clot-related problems. Most received their wheelchairs from government, charity or family or friend. For most users, the current wheelchairs were basic indoor wheelchairs (91%) and few wheelchairs had cushions (28%). In both countries, most users received the wheelchair at no cost. Because of a concerted effort to find users who received services and the expansion of eligibility criterion, 16% of the sample in the Philippines had received their chair more than 5 and less than 10 years before the survey.
Wheelchair services received
In each country, approximately 40% of the participants were classified in the service-received category according to the response to the screening question. In Kenya, for the current wheelchair, a third of participants received wheelchair assessment (31%), a third of participants received wheelchair fitting (34%) and 42% were fitted while the user propelled the wheelchair (Table 2). Few participants received any other services with the current wheelchair. Regarding services ever received in the lifetime, just over a quarter of participants received wheelchair training; similarly, 26% ever received instructions in taking care of the wheelchair; 41% reported that a provider had ever helped choose the right wheelchair. Few participants had ever been told where to seek help with repairs (15%) or had ever been contacted by the provider in follow-up (15%). The question on skin problems is not reported on because of an issue with the programming of this item in the software.
In the Philippines, for the current wheelchair nearly a third of participants received wheelchair assessment (31%), a quarter received wheelchair fitting (26%), and 39% were fitted while the user propelled the wheelchair. Few participants (15%) reported that a provider had asked about or physically checked the user for skin problems or pressure sores; 10% were checked for unsafe seat pressure. Regarding services ever received in the lifetime, 17% of participants had received wheelchair-related training, a quarter of participants received provider instructions in taking care of the wheelchair and 40% reported that a provider had ever helped choose the right wheelchair. Few participants had been told where to seek help with repairs (18%) or were contacted by the provider (20%).
Wheelchair-related outputs and outcomes
In Kenya, most participants (60%) reported using the wheelchair daily for 8 h or more and 80% independently performed at least three of the four assessed ADL (Table 3). Only 25% of participants used their wheelchairs outdoors unassisted in the past month. Falls were common; 22% had ever had a serious fall, while 37% reported a non-serious fall.
In the Philippines, 42% of participants used their wheelchairs for 8 h or more and 16% used it 1-7 h daily. Most participants (73%) independently performed at least three of four ADL. A third (33%) of participants used their wheelchairs outdoors unassisted. Two-thirds of Filipino users had not fallen (66%).
Bivariate results
Daily wheelchair use was associated at p < 0.05 with one service variable in Kenya, 'provider ever instructed user in taking care of wheelchair'. In the Philippines, daily wheelchair use was associated at p < 0.05 with 10 service variables: 'assessment with current chair', 'fitting', 'assessment of wheelchair fit while user propelled wheelchair', 'provider asking or physically checking user for skin problems, sensation or pressure sores', 'assessment duration: < 30 minutes', 'training ever received', 'provider ever helped user choose the right wheelchair', 'provider ever instructed user in taking care of wheelchair', 'provider ever told user where to seek help with repairs' and 'peer group training'.
In Kenya, reporting at least a non-serious fall versus no falls at the bivariate level was associated with three service variables: 'assessment duration of less than 30 minutes', 'provider ever helped user choose the right wheelchair' and 'provider ever instructed user in taking care of wheelchair'. In the Philippines, reporting a non-serious fall versus no falls was associated with the same 10 service variables as for wheelchair use.
High performance of ADL was associated at p < 0.05 with three service variables in Kenya: 'provider assessed wheelchair fit while user propelled wheelchair', 'provider asked or physically checked user for skin problems, sensation or pressure sores' and 'training ever received'. High performance of ADL was associated with nine service variables in the Philippines. These were the same as for daily wheelchair use, except for 'provider ever helped user choose the right wheelchair'.
Outdoor unassisted wheelchair use was associated with three service variables in Kenya: 'assessment', 'assessment of wheelchair fit while user propelled wheelchair' and 'training ever received'. In the Philippines, outdoor unassisted wheelchair use was associated with the same 10 service variables as for wheelchair use.
Multivariable model results
The wheelchair use outputs associated with wheelchair service items in multivariable models are presented in Table 4.
In Kenya, one service item was associated with daily wheelchair use: the provider ever contacting the user about the wheelchair use was associated with reduced odds of daily wheelchair use (OR 0.4, 95% CI 0.2, 0.9). No service item was associated with odds of falls.
In the Philippines, four service items were associated with daily wheelchair use. Ever receiving wheelchair training was associated with 4-fold increased odds of high versus no daily use (95% CI 2.3, 7.0). A provider helping the user choose the right wheelchair ever was associated with 2.8-fold increased odds of high versus no daily use (95% CI 1.1, 6.9). However the provider of the current wheelchair asking about or checking user for skin problems, sensation or pressure sores was associated with reduced odds of high versus no daily use (OR 0.5, 95% CI 0.2, 0.97). Ever being instructed in taking care of wheelchair was also associated with reduced odds of high versus no daily use (95% CI 0.2, 0.91).
In the Philippines, four service items were associated with increased odds of falls. Ever being told where to seek repairs was associated with 6.1-fold increased odds of serious versus no falls (95% CI 2.0, 18.4). Longer assessment duration was associated with increased odds of serious versus no falls (95% CI 1.3, 4.5). Ever receiving wheelchair training was associated with 2.5-fold increased odds of serious versus no falls (95% CI 1.4, 4.5). Peer group training was associated with 2.1-fold increased odds of serious versus no falls (95% CI 1.1, 4.0).
Wheelchair service items associated with outcomes of high performance of ADL and unassisted outdoor use in multivariable models are presented in Table 5.
In Kenya, three service items were associated with the outcomes ever having been told where to seek repairs, was associated with 2.8-fold increased odds of unassisted outdoor use (95% CI 1.5, 5.0). Two service items were associated with odds of high performance of ADL. Ever being trained was associated with 3.2-fold increased odds of high ADL performance (95% 1.3, 8.4). Having the fit of the wheelchair assessed while the user propelled the current wheelchair was associated with 2.8-fold increased odds of high performance of ADL (95% CI 1.6, 5.1).
In the Philippines, two service items were associated with the outcomes. Having the fit of the current wheelchair assessed while propelling was associated with (1) 2.4-fold increased odds of using the wheelchair outdoors unassisted (95% CI 1.5, 4.1) and (2) 2.8-fold increased odds of high ADL (95% CI 1.8, 4.5), a similar finding to Kenya. However, the provider doing the assessment or fitting at the wheelchair user's home was associated with reduced odds of outdoor unassisted use (OR 0.40, 95% CI 0.4, 0.9).
This study is one of the first to present survey findings from less resourced settings examining specific wheelchair services received and the relationship to user outcomes.
Documenting the effectiveness, efficiency and costs of wheelchair service and distribution programmes is an imperative for funders and programme managers to better meet client needs (Harris & Sprigle 2008). As governments consider how to meet the needs of wheelchair users under national insurance schemes, information on outcomes will be important in establishing coverage priorities. As recommended by Harris and Sprigle (2008), this study in Kenya and Philippines assessed unassisted outdoor mobility and independent performance of ADL and falls.
Findings, explanations and prior research
Large studies with wheelchair users are rare. In this study in Kenya and the Philippines, wheelchair users who received and did not receive services with their current wheelchairs or in their lifetime were recruited and it was difficult to find users who had received wheelchair services. Similarly, Zongjie et al. (2007) found that while 75% of disabled residents in a Beijing sample expressed a need for rehabilitation, only 27% had received any services. Where wheelchair services are more available, users may be more often informed about or referred to rehabilitation services.
The provider assessing the fit of the wheelchair while the user propelled the wheelchair was associated with greater odds of high ADL performance in both countries. Providers fit clients as they propel in order to determine how the wheelchair user performs certain functions in the wheelchair. When the wheelchair is tailored to the functional needs of the user, performance of ADL may be facilitated.
Training in wheelchair use ever was positively associated with high daily wheelchair use in the Philippines and performance of ADL in Kenya, adding to literature on the safety and effectiveness of wheelchair skills training (for instance Best et al. 2005, 2016; Kirby et al. 2016a; MacPhee et al. 2004; Ozturk & Ucsular 2011; Routhier et al. 2012; Worobey et al. 2016; Tu et al. 2017). Higher odds of reporting falls were associated with receipt of training in Philippines. It may be that trained users had greater confidence to use their wheelchair in new places on rougher terrain or for longer distances without adequate protection and, therefore, incurred more falls. However, it is possible that the nature or dose of the training was suboptimal or the competencies achieved were inadequate. Also, users may have been overconfident following training.
Three provider actions related to wheelchair assessment and fit were negatively associated with three outcomes in the Philippines even while controlling for user characteristics, and several factors may explain this finding. Firstly, in the cultural context, elderly people and people with disabilities may not be expected to be independent, the assistance of a family member or carer is expected, and using of wheelchair outdoors may be associated with stigma in the setting (Tanudtanud-Xavier 2013). Secondly, the environmental context and limited public transport may preclude independent wheelchair mobility. Thirdly, the provider's actions may have been a response to the user's low daily wheelchair use, outdoor wheelchair use or ADL performance. In a household survey conducted in Beijing, China, having received rehabilitation services was associated with a lower functional independence measure score (Zongjie et al. 2007). The authors concluded that Beijing residents in need of rehabilitation lacking functional independence were seeking out services to improve their situation.
In our study, the user being told where to seek repairs was associated with outdoor unassisted wheelchair use in Kenya and falls in Philippines. Outwardly oriented users may have sought out information on wheelchair repairs. In Philippines, advice on how to repair wheelchairs or get spare parts may have followed chair breakdowns and falls (Williams et al. 2016). Possible factors related to this outcome may be fewer accessible environments and more available compatible parts and repair services.
There were low levels of unassisted outdoor wheelchair use. Generally, in Philippines and urban Kenya, many residential communities for people of limited economic means are not wheelchair accessible. Communities with narrow walkways and small houses may have required wheelchair users to seek assistance from others for mobility.
In a cross-sectional survey, the temporal order of events cannot be confirmed and causality cannot be determined. Questions referring to a past time period may be influenced by recall bias. This study's results are not directly comparable at this time to other studies. The survey instrument was informed by existing instruments and developed for the specific goals of the study, as was done in other studies of assistive technology (Borg et al. 2012).
Although the survey had many modules to answer key research questions and was comprehensive, certain questions in the survey had limited response possibilities. For example, the question on type of wheelchair's response category of indoor chair does not indicate if the chair was for short-term hospital transport or intended for longer term use. The outcome of daily wheelchair use does not reflect the users' functioning while in the wheelchair. It is not possible to know whether wheelchair falls are related to improper wheelchair use.
Generalisability of this study to the national populations of adult, basic wheelchair users is limited by the sampling strategy of recruiting in equal numbers users who received wheelchair services and those who did not. Reported levels of wheelchair services received in this study may be different than those of the national population of wheelchair users, and this can be assessed in a national survey.
Recommendations for practice or programmes
The study findings were disseminated back to local authorities, wheelchair user and service delivery organisation stakeholders in well-attended meetings in both the Philippines and Kenya, and wheelchair stakeholders were advisers to this study from the beginning. This active engagement of local wheelchair stakeholders and users led to an outpouring of ideas on how to improve policy and programmes.
Training in wheelchair use is related to better wheelchair use outcomes and should continue to be emphasised and delivered in an efficient and equitable manner (Tu et al. 2017). Opportunities should be sought to provide basic wheelchairs partly through peer group workshops, and peer group training should be evaluated (Best et al. 2016). For countries that have an established and working community strategy, engaging community health volunteers can be explored as a mechanism for training wheelchair users.
The provider assessing the fit of the wheelchair (e.g. using the objective version of the Wheelchair Skills Test [Kirby et al. 2016b]) while the user propelled the wheelchair should be an emphasised element of the WHO service package. The provision of wheelchairs and services needs to include a plan for wheelchair maintenance (Toro et al. 2016) and access to spare parts. Wheelchairs should be distributed with a user's manual and a basic toolkit. Local artisans can be trained to help with maintenance and repair of wheelchairs.
The need for follow-up of wheelchair users and an understanding of their home context and possibility for social and economic integration is paramount, and greater emphasis should be placed on service providers advocating for independent home accessibility for wheelchair users (Scovil et al. 2012. Providers can also engage existing community networks to aid in follow-up of wheelchair users.
Prevention of falls during wheelchair use can be promoted through use of durable chairs with the appropriate weight balance (Toro et al. 2016), fall-avoidance training (Kirby et al. 2016b) and advocacy to change the physical environment to be more manageable to independent wheeled mobility. Self-advocacy training should be added as an element of the WHO service package so that empowered wheelchair users can demand better quality services from service providers, and WHO managers training should be taken up by service managers.
Regarding ADLs, the access to safe water and sanitation affects all persons with special considerations for wheelchair users in less resourced settings (Scovil et al. 2012). WHO should add a service element of counselling in which providers' explore access to safe water and use of sanitation facilities as an element of activities of daily living.
In the policy domain, governments should establish an evidence-based minimum service package to be delivered along with wheelchairs. Wheelchairs produced locally and imports should be regulated to ensure that all wheelchairs meet specifications for less resourced areas. Providers should consider the costs of wheelchair services when budgeting and should explore public-private partnerships to strengthen the delivery of wheelchairs compliant with standards from the International Standards Organisation.
Tax relief should be enacted to make a wider range of wheelchairs more affordable. Governments should enforce current laws compelling public buildings and transport systems to be accessible to people with disabilities.
Because follow-up with wheelchair users has been largely overlooked, several approaches may be considered: enabling wheelchair provider-initiated contact by embracing eHealth and telemedicine and engaging with community health workers. It may be useful to set up a telephone hotline for wheelchair users. In Romania, a toll-free telephone hotline provides information and referrals to callers on appropriate wheelchairs and services (personal communication between Fundatia Motivation România staff and first author, 07 June 2016).
Providers can make efforts to fit every wheelchair user while the user is propelling the wheelchair. When a user is unable to propel, this may suggest difficulties with unassisted mobility and ADL performance in this wheelchair in the long run. Providers can discuss with clients who request or need at-home services and discuss maintenance and repair with clients. The availability of appropriate wheelchairs and spare parts is imperative at the national level.
Recommendations for future research
It is recommended for wheelchair service organisations or contracted evaluators to collect contact information from all persons in need of wheelchairs, those who receive wheelchairs and services and their support persons and to keep this information secure and confidential. With additional contact information, service organisations can follow-up with wheelchair recipients over years to ascertain outcomes of wheelchair use and satisfaction, health and well-being, and mortality (Scovil et al. 2012). A long-term study of wheelchair users' service exposure and outcomes may need to be achieved through funding mechanisms that fall outside that of a typical international development grant period (USAID 2014).
Future population-based surveys of persons with disability should use validated functional measures and plan to further validate scales in the local context, as done by Toro et al. (2016) in Indonesia. The Spinal Cord Independence Measure may be a useful instrument (Anderson et al. 2008) for persons with spinal cord injury. The Wheelchair Skills Test Questionnaire (Kirby et al. 2016b) allows for measurement of wheelchair skills capacity, performance and confidence. Use of Craig Handicap Assessment Recording Technique Short Form (CHART-SF) will allow for measurement of outcomes in multiple domains (Whiteneck et al. 1992).
Wheelchair use outcomes and ADL could be measured by additional means, such as user diaries about the use of different wheelchairs for different activities. Medical records or visits by a study nurse to study participants could help validate reports of adverse health outcomes. Wheelchair use could be measured by accelerometers or global positioning system for measurement of distance travelled or outdoor mobility (Sonenblum et al. 2012). Furthermore, observations by trained observers would provide additional information to understand outcomes (Rispin & Wee 2014).
Kenyan wheelchair stakeholders recommended that future research should incorporate questions targeting wheelchair users in national surveys. Kenyan wheelchair stakeholders would like a study to examine the impact of service receipt on children who use wheelchairs and the costs and affordability of chairs. In addition, questions on wheelchair users can be incorporated into existing standard reporting tools used by community health volunteers of the Ministry of Health. Stakeholders in the Philippines recommended creating a central repository data from various studies involving wheelchair users. It was emphasised that wheelchair users be involved in all phases of research. It is important to evaluate service delivery models as done by Toro et al. (2016).
In a two-country survey of over 800 adult basic wheelchair users, select services that were associated with some better wheelchair use outputs and outcomes should be emphasised in service delivery. Specifically, assessing the fit of the wheelchair while the user propelled the chair and training in wheelchair use are services associated with positive wheelchair use outcomes. Serious falls may be an unintended consequence of increased mobility. Efforts to provide wheelchairs and services need to include plans for wheelchair maintenance and repair and follow-up with wheelchair recipients.
The authors would like to thank Jhpiego staff Deepti Tanuku, Accelovate Director, and staff in Kenya and the Philippines, including Dr Bernabe Marinduque. The authors are grateful to the Institute for Health Policy and Development Studies, University of Philippines Manila, for leading the Philippines data collection and to the surveyors in both countries. This research would not have been possible without the many devoted representatives of organisations in Kenya and of local government units and barangays in the Philippines who helped the authors reach the wheelchair users. Finally, the authors express their gratitude to the more than 800 wheelchair users who were participants in this study, as well as the caregivers who supported their participation. The authors thank Mr Peter Mbuguah for advice on study location and comments on the article.
This study was made possible through the generous support of the American people through the US Agency for International Development (USAID), under the terms of the Technologies for Health award AID-OAA-A-11-00050. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the US Government. The research was carried out by Jhpiego's Accelovate programme, whose goal is increasing the availability and use of life-saving innovations for low-resource settings. The funder was involved by receiving monthly updates from the research team, offering guidance and global knowledge of wheelchair service programmes and approving yearly work plans. The funder was not involved in data collection, analysis, interpretation or writing of the study report or the manuscript.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
E.S.B. was the principal investigator of the study and was involved in all phases of the research from inception, led the analysis and was lead writer of this article. E.J.H.H. was involved in all phases of research from inception, participating in the study design, the oversight of data collection teams and the interpretation of findings. B.N.O. participated in all phases of the study from the study design, coordination of the study in Kenya, interpretation of findings and helped draft the manuscript. E.K.W. participated in the study design and implementation and helped draft the manuscript. J.H.N participated in all phases of the study from inception, study design and interpretation of findings. C.A.X. was the technical coordinator for the study in the Philippines and participated in the acquisition of data, analysis, interpretation and dissemination of findings to stakeholders.
F.D.S.G. helped in the acquisition of data and participated in the analysis and interpretation of the data. A.G. was responsible for achieving project objectives in Kenya including overall direction, including oversight over local dissemination of the results to stakeholders and contributed intellectual inputs to the manuscript. M.G. provided input on the policy implications of the research findings and added inputs to the manuscript. P.M. participated in the research consultative meeting and provided inputs on the policy implications of the research findings. R.L.K. participated in the study design, the interpretation of the findings and the drafting of the manuscript. All authors read and approved the final manuscript.
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Eva Bazant
Eva.Bazant@jhpiego.org
Received: 22 Sep. 2016
Accepted: 03 Apr. 2017
Published: 20 Oct. 2017
Table 1 -A1 - Click to enlarge
Figure 1-A1 - Click to enlarge
AOSIS Publishing
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This creative, savory recipe is reminiscent of a quiche or tart filling, but sturdier and easy to portion out or take on-the-go.
Combine the mix, melted butter or oil, milk, and egg, stirring until nearly smooth. Allow the batter to rest for 5 minutes to thicken.
Pour the batter into the prepared pan, spreading it to the edges of the pan and smoothing it out.
Sprinkle your choice of toppings (meat, vegetables, cheese) over the batter.
Bake for 25 to 30 minutes, until the center springs back when gently pressed and the edges are starting to brown.
Remove the pan from the oven. Cut into squares and serve warm.


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Does Canada not deserve its own exclusive national dairy showcase? This was the question that CDX founder Jordon Underhill found himself asking when crossing the border from another World Dairy Expo road trip, to Madison Wisconsin. A cow crazy Canadian, 15+ years of travelling to international dairy events and a passion for advancing the Canadian dairy industry, all led to the inception of the CDX concept. Jordon felt strongly that the Canadian dairyman was well respected globally for genetic excellence and early adoption of innovation, but needed a national platform for continuous improvement and global showcase.
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Has anyone ever tried the fruit pies from this relatively new place in Kennett? Their online menu looks impressive AND pretty pricey. http://www.nomadicpies.com/#!menu/ch8j They sell by the slice, so I guess that's a safe way to try without making a major investment ($23 for a 9" pie!). But I'd love to hear from anyone who's tried any of their fruit pies.
And while I'm on the subject of pie – who else in southern Chesco makes really great fruit pies? Thanks!


I have posted my baked peanut butter oatmeal, a baked peanut butter chocolate chip version, and my baked pumpkin oatmeal. I even posted my soy butter version that my daughter enjoys.
All of these are family favorites and we enjoy them, but today I have yet another version for you that we love and it is Baked Banana Oatmeal.
I love these baked oatmeals because not only are they easy to make, they are a healthy breakfast that my kids love.
This version is a basic baked banana oatmeal that we add chocolate chips to. The banana version is one of the most versatile of the baked oatmeals that I have come up.
I think it would be good with nuts and cinnamon added instead of the chocolate chips. This would make it a banana nut baked oatmeal. You could also easily add peanut butter to it and make it peanut butter banana baked oatmeal or peanut butter, banana, chocolate chip.
There are so many ways you can make this and that is what I love about the basic baked peanut butter oatmeal recipe that I came up with. They are all so easy and so good!
Some of you have already shared with me that you have experimented and come up with a banana version and others versions that you love. I am so glad that many of you enjoy the baked oatmeals as much as we do.
Look for more fun variations coming next month. I have a few more to share.
sounds good! Might have to give this a try for breakfast in the morning :o) Thanks for sharing!
We have tried and love your other versions and now I can't wait to try this. My little guys eat it like a cake but we love the milk added to our bowls. Your breakfast recipes keep variety in my menus.
This sounds AMAZING! I LOVE the taste of baked/cooked bananas. Many people don't realize that they take on totally different, sweet and yummy taste when cooked! My kids used to love oatmeal, but they haven't really liked it as much lately, which bums me out because it is so good for them, so I am hoping that something like this, that also has bananas, which they love, in it, will get them eating it again! 🙂 Can't wait to try it! Glad I found your site!
@Kelley, I agree bananas taste very different cooked. We love them both in baked goods and just plain. I am so glad you found my site. Thanks for reading!
Sounds yummy! How many portions this makes? Seems like it may be a lot for our family of three. Does it taste good reheated later?
@Marta, I have three kids, so five in our family and this is just about one breakfast for us. Yes, it reheats well. I often double it so that we can get a couple of breakfasts out of it. I hope that helps.
This sounds like such a comforting breakfast. I love baked oatmeal and think your variations sound fantastic!!
Yum, this is getting me ready for breakfast. I'd love it if you came and linked this up to my Holiday Recipe link party. This would be perfect for Christmas morning.
Oh my goodness this looks so yummy and easy too! Thanks for sharing!!!!
Could you substitute old-fashioned rolled oats and how would you change the recipe for that?
@Chris, I have not tried it with the banana version, but I have with some of my other versions and yes it works, but the texture is a little different. I hope that helps.
Just thought I'd add that I made this this morning and it was awesome. But, after making it and eating it I realized I had forgotten the brown sugar. And it was still great and plenty sweet with the bananas and chocolate. Thx for the recipe.
We loved this. Tastes just like Banana Bread. I left out the chocolate chips and added walnuts (no nut allergy here).
@Tannis, I am so glad that you enjoyed this. And yes it does taste a lot like banana bread.
@Sharon, I probably could just about make it in my sleep. And I still have another couple of versions to post about. 🙂 I love them all and so do my kids. So easy and so good!
yum! can't wait to try this and the peanut butter one!
@MicheleR, I hope you enjoy it. Both are a favorite in our family.
Stupid question, but do you store covered in the fridge or covered on the counter? Can't wait to make & try it!!
@Kim B., I store the leftovers covered in the fridge. I hope you enjoy it!
This sounds absolutely delicious!! We did love the peanut butter oatmeal, so definitely have to try this one now! 🙂 Thank you for these awesome recipes!
@Sandra, I hope you enjoy it! My kids love it especially when I add a few chocolate chips.
My daughter and I made this for breakfast this morning and it was SO good! New things can be hit or miss with my 2 year old but she gobbled this right up!
I also want to tell you I've tried and love lots of your recipes! Your blog is definitely a go-to for me when I"m looking for something new!
@Sarah, Thank you! I am happy to hear that your daughter enjoyed it. It is a favorite with my kids also.
Oh yummo! Just made it to eat over the next couple days during my work stretch as a nurse. This is way better than I thought it would be! Only thing I did different was used honey instead of brown sugar! Thanks!
Just wondering if you've ever tried mixing up baked oatmeal the night before, and how it turned out?
My other baked oatmeal recipes work great made up the night before and baked in the morning. This banana one though is not as good when made up the night before. The mashed bananas do not hold up well and they turn brown. However, I do like to make a large batch of this and any of my other baked oatmeal recipes bake them and reheat them throughout the week for breakfast. That works great! I hope that helps and that you enjoy the oatmeal recipe.
I agree. This is a great gluten free breakfast. I am so glad you enjoyed it.
I just made this for my daughters today and they both enjoyed it. Although I do have plenty of leftovers for the week! I am going to refrigerate a couple of chunks for tomorrow's breakfast and freeze the rest so they can have "instant" oatmeal at hand.
Made it for breakfast this morning for the first time. It was so good(even without the chocolate chips). My first time eating baked oatmeal and I think we'll be making it again soon! Thank you!
I made this for breakfast this morning and it was quick and easy. The kids declared it delicious!
I just plugged this recipe into Sparkrecipes.com and found that with 1% milk and walnuts instead of chocolate chips there are only 234 calories per serving (with the entire recipe making 10 servings). That's not too shabby! I think I'll be making this pretty soon! Thanks for the recipe!
Any suggestions for trying these baked oatmeal recipes without eggs? My son has a severe egg allergy, so I'm wondering what a good alternative would be. We can't use egg replacers, but sometimes find ground flaxseed mixed with water to be a good option. Sounds delicious!
The egg acts mainly as a binder and for texture, so yes I would try the flaxseed and water. I think that should work pretty well in place of the egg.
He must really like it to think of it as dessert. 🙂 But that is so cute! I agree this is so kid friendly. Mine eat it all the time and love it!
I made this today and it was so delicious! I'm diabetic so to cut back on the extra carbs I added walnuts instead of chocolate chips, it can even stand to cut back on the brown sugar so I'm going to try 1/3 cup next time. Thanks for the recipe!
I love nuts added to this, but since my daughter is allergic to all tree nuts and peanuts, we now have to avoid them. A little peanut butter added to this is also good. 🙂 I am glad to know that cutting back the sugar worked for you. Thanks for letting me know how much you enjoyed it!
This is a really good recipe. I made 1/2 the amount for two people. I added 1/2 the brown sugar inside and 1/2 to the top when there was only 4 minutes of cooking time left. Put it on broil for the last 2-3 minutes so that the top got crispy and caramelized. Tip: don't try to add sliced bananas to the top because they turn black…Very good recipe, very decadent!!
My oldest son is 4 and has never eaten any type of oatmeal until your baked oatmeal recipes. He loved them from the start. THANK YOU so much. It is so nice to get a healthy breakfast in him. Great site with many good recipes.
I am trying this tonight! I looked up the calories the way the recipe is and added a 1/2 cup skim milk to poor on top and came up with 192.2 calories per serving- I put that it makes 9 servings… sounds pretty healthy to me!! Thank you for the great comfort food 🙂 Do you have a recipe for a raisin cinnamon oatmeal bake? Thanks again!
Yes, I have a version, but it is not posted. I will try to share that this fall.
I would really like to try this recipe! I was wondering how I would change it to use steel cut oats. Any thoughts?
I have never tried it. I would probably work, but you might need to adjust the liquid and cooking time. I would love to hear how it turns out if you try it.
Hi Lynn, thank you so much for this recipe. Made it yesterday for breakfast and shared some with one of my gym friends. Everybody loved it so much.
I am glad everyone enjoyed it. It is one of my family's favorite ways to eat oatmeal and I love hearing that others enjoy it as well.
I can't wait to try this! Perfect timing! For the first time in a year I have 3 overripe bananas on my counter. My 6 year old will definitely help make this today. Thanks!
I hope you enjoy it! It is a great recipe for kids to help with.
I am loving your baked oatmeal recipes!!! Just made this one and my whole family adored it!! Thank you for sharing!
Oh yes, and I saw someone was wondering about using frozen (thawed) bananas, I always do this and I used frozen thawed bananas for this recipe and it worked perfectly!
I am glad to know that works. I have used frozen bananas for other things, but I don't think I have ever used it in this. So thanks for letting us know it works.
I make this all the time (and other variations) and love it! But I'm wondering, have you ever tried doing it in muffin tins?
Yes it can be. In fact all of my baked oatmeal recipes work great as "muffins". I like to make them that way and then freeze them. You simply make up the baked oatmeal and cook it in a greased muffin pan at 350 degrees for 15-18 minutes. It works great. I hope that helps.


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ICNTN Series
Practical Pharmacological Management of Tics
Hemali Vaghariya Updated November 05, 2022
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Topic : Practical Pharmacological Management of Tics
Speaker : Prof. Jonathan Mink
When : November 12, 2022, 9 to 10 AM EST ( US/Canada )
To register for this webinar, please click here
Prof Jonathan W. Mink, MD PhD is the Frederick A. Horner Distinguished Professor in Pediatric Neurology and Professor of Neurology, Neuroscience, and Pediatrics at the University of Rochester ( NY ) where he is also Chief of Child Neurology and Vice Chair of Neurology. Dr. Mink received his BA ( Biology-Psychology ) and MA ( Psychology ) from Wesleyan University and hid MD and PhD ( Neuroscience ) from Washington University. He completed residency training in Pediatric and Pediatric Neurology at Whashington University / St. Louis Childern's Hospital. After completing a fellowship in Movement Disorders, he joined the faculty at Washington University in 1994 before being recruited to the University of Rochester in 2001. He launched the University of Rochester Child Neurology Residency in 2003. He stepped down as Program Director in 2013, but continues to have an active role in resident education.
Dr. Mink has an active research program focused on Batten Disease and movement disorders in children. Clinically, he specializes in Pediatric movement disorders with special interests in dystonia and Tourette Syndrome. He is recognised internationally for his work and clinical expertise in Pediatric movement disorders, Batten Disease and basal ganglia physiology. He was the recipient of the first Dr. Oliver Sacks Award from the Tourette Association of America in recognition for his many contributions to Tourette Syndrome Research, Education and Advocacy.
Dr. Mink currently serves on several advisory committees including the Executive Board of the International Child Neurology Association, the Executive Committee of the CNCDP-K12 program and the NINDS NST-1 Study Section. He is a past member of NINDA Advisory Council, the NINDS Board of Scientific Counsellors and the FDA Pediatric Advisory Committee. He is past-chair of the Tourette Association of American Scientific Advisory Board. He has served as Associate Editor of Neurology and of Continuum . He is former President of the Child Neurology Society and was the 2021 recipient of the Hower Award from the CNS.
Zimbabwe Appeal
ICNA Zimbabwe appeal for upskilling & capacity building in child neurology
Sahar Mohamed Ahmed Hassanein ACNA
1 week ago Editing
Wishing you all the best for a happy and successful 2023!
The countdown to ICNC24 has begun in earnest and we are so excited, check out our great logo
Please see e-mail below requesting Symposia Proposals which we would like to be...
Please see e-mail below requesting Symposia Proposals which we would like to be distributed to your units and to all ACNA members.
Symposia proposals: Deadline - March 30, 2023
The ICNA is please to invite Symposia Proposals for the 18th International Child Neurology Congress - ICNC2024, May 6-10 Cape Town, 2024. We welcome you to submit proposals for Symposia for the 18th International Child Neurology Congress that will take place in Cape Town, South Africa from May 6-10, 2024. All proposals must be submitted through this website before March 30, 2023 at 5 pm EST. https://icnapedia.org/forms/icnc2024/symposia/
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LAURA MCCULLOUGH
Natasha Tretheway and inbetween-ness
Natasha Trethewey's poetry of family and historic violence and personal racial hybridity is the subject of Timothy Leyrson's "Writing Between Worlds".
Trethewey's views of her bi-racial identity, and race relations overall, are beneficial for a number of reasons. By embracing these concepts she is able to create deeper meaning in her own expression, for her readers who are bi-racial she develops a common bond, and readers of a singular racial background are forced to examine the world beyond their own perception. But perhaps the highest level of understanding is that her views may be acting as a method of transformation. The idea of being united in one's own mind, as well as to others, it is explained by Trethewey herself in a lecture she delivered in Emory University's Distinguished Faculty Lecture series on February 3, 2010. Trethewey stated: I believe, after all, that poetry is the best repository for our most humane, ethical, and just expressions of feeling. This is because poetry ennobles the human soul, that it opens—not closes—our hearts. Poetry matters...
For the full essay and all of the others, get the anthology here.
Writing, Making Music, Working with people, & Loving & Living in New Jersey
A Sense Of Regard
Leslie McGrath
R. Dwayne Betts
Tony Hoagland


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Classical Period Orchestra Instruments Woodwind Family
June 11, 2019 | By admin | Filed in: Blog.
The saxophonist and flutist Frank Wess, whose time in the woodwind section of the Count Basie Orchestra propelled. also started studying the flute with orchestral musicians; he would later help.
Conically shaped, the saxophone is the only woodwind instrument made of brass. Although it is found only occasionally in the symphony orchestra, it is considered a member of the woodwind family because it has a single reed like the clarinet.
Yet they played just as seriously Saturday for the grade-schoolers and their families in the hard. Many in the crowd had never heard classical music before, much less attended a concert. The.
Even now, more than 50 years after it all began, the period-instrument. the differences between the orchestral instruments of that time and those of today may be much smaller than, for instance,
The oboe shares some common ancient ancestry with others in the woodwind family, most especially the bassoon. Both instruments evolved from a family of Middle Age instruments known as shawms, which were themselves descendants of Greek and Roman double-reed instruments known as "aulos" that saw use primarily in military settings.
Internationally, his compositions had been featured by world-class orchestras at concerts worldwide, such as the Madrid Classical Orchestra of Spain. and he went on to play other woodwind.
Twenty years ago this month, EMI brought out a box set of the complete Beethoven symphonies that the London Classical Players and I. This pure tone from every instrument in the orchestra – woodwind.
The Membrane In The Ear Is Named For What Musical Instrument? Not only did all this underline the meaninglessness of the word "indie" nowadays, it reminded me of the endless, endless 1980s revival that. Membranes/Bogshed style shambling bands, the. Hurdy-gurdy is the (imitative) name for the instrument with a droning sound played by turning a handle, which is typically attached to a rosined wheel sounding a
Tickets on sale now! Call or visit the box office to purchase tickets during regular business hours, or follow the link to the right to buy online 24/7.
Musical instrument: Musical instrument, any device for producing musical sound. The principal types of such instruments, classified by the method of producing sound, are percussion, stringed, keyboard, wind, and electronic. Learn more about the characteristics and classification of musical instruments.
The oboe, a long reedy apparatus, is an overlooked member of the woodwind family. Yet it's the instrument that the rest of the orchestra tune themselves. have for young people considering a career.
NEW DELHI: The Storms, a talented family. Orchestra of Holland. Annelies plays flute in the orchestra of the University of Leiden. She also gives music classes to basic school pupils. Ger has.
to the strictest of historically informed accounts from specialist period bands. Jos van Immerseel's accounts are close to the historically purist extreme of that spectrum; his Belgian orchestra Anima.
It took decades—a century even, depending how you count—for Adolphe Sax. woodwind families, the instrument is the perennial Cinderella of serious music. Its rich, sometimes dozing sound has never.
The standard orchestra that most of see these days consists of four sections: strings, woodwind, brass, and percussion. In each of these we have standard instruments, approximately four different instruments per section (not counting percussion). Not all composers, however, choose to limit.
The young Salieri got to know Pietro Metastasio, the reigning librettist of eighteenth-century Italian opera, and Christoph.
On rare occasions, a divorce benefits every member of a family – even when there are. The Davidson-based N.C. Baroque Orchestra will play a smaller-scale "Messiah" on period instruments such as.
Daniel Barenboim and the West-Eastern Divan Orchestra placed Boulez. Refreshing, too, to hear Beethoven on modern instruments, unencumbered by the raggedy edges and cardboardy drums that can.
The term "wind" instrument includes the woodwind family and the brass family, because they all use the players breath to produce sound. Brass instruments are a different family though, because they are/were never made of wood, and sound is produced with a metal funnel mouthpiece.
Oct 28, 2005 · Highest Sounding Woodwind Instrument? – posted in General Music Forum: HiThis is a question for Grade IV theory. Which is the highest sounding instrument in the "Standard Orchestral Woodwind Family?"Shall I answer piccolo or Flute? I know piccolo goes higher than flute but in the Workbook, they mentioned only Flute, Clarinet, Oboe and Bassoon in the Standard Orchestral Family…
Woodwind Instruments. Clarinet – The clarinet is a popular single reed instrument. It's used in classical, jazz, and band music. There is a wide variety of clarinets making the clarinet family the largest of the woodwinds. Oboe – The oboe is the highest pitch member of.
As far as I'm aware, this is the first period-performance of a Bruckner symphony on disc. Herreweghe's forces are modelled on the line-up of the Leipzig Gewandhaus Orchestra in 1881, with gut strings.
It incensed them that classical music—for a brief period. orchestra to no less an eminence than Artur Rodzinski, the music director of the Cleveland Orchestra, who selected the best players from.
An emotive classical inspired track. Features woodwinds, glockenspiel, and orchestral percussion.Would work well in historical films, documentaries about the elite life of royal family and high class society, pastoral scenes, and nostalgic settings.
The woodwind family of instruments is a subset of the more general category of wind instruments. Within the woodwind family, there are two main types of instruments: reed instruments and flutes. The reason reed woodwind instruments are identified as "woodwind" is based on the way they produce their sound which is by splitting the player's.
Since he launched the orchestra 14 years ago, François-Xavier Roth has specially focussed his concerts on French orchestral music from around the turn of the 20th century, with the period instruments.
Often performances by such musicians are said to be "on authentic instruments". This article consists of a list of such instruments, including both instruments that are now obsolete and early versions of instruments that continued to be used in later classical music. This list only includes woodwind, keyboard, and brass instruments.
Woodwinds- Originally, this was an instrument that emits sound when air is blown through a wooden tube or pipe. Modern woodwind instruments (flutes excluded) create sound when air is blown over a wooden reed attached to a mouthpiece. Flute- Metal instrument that emits sound when air is blown over an opening at the top of the instrument.
Enjoyable and exhilarating'. Jennifer Pike performing at the Family Prom. Photograph: Chris Christodoulou The point of this Family Prom is to introduce children to classical. the orchestra's.
Indiana Jones And The Last Crusade Scherzo For Motorcycle And Orchestra Who Is Singing At Simp Mcghees Aug 12 2019 Decatur Al Several items in the news recently caught my eye. Reading about the Apollo 10 mission that took place exactly 50 years ago gave me a good feeling. While I vividly remember as a 9-year-old. (click. Eula Clyde Scruggs, 95, died on Friday, August 6,
In the past two years, the Honolulu, Syracuse, and New Mexico orchestras closed up shop entirely; the Philadelphia Orchestra. or any instrument that does not afford the possibility of soloist.
Home » World Instruments » Wind Instruments Wind Instruments Bagpipe Practice Chanter. The bagpipe practice chanter is a double reed woodwind instrument that.
Violin; regularly leads the Orchestra of the Age of Enlightenment I've heard mutterings from fellow violinists that the system isn't really fair, but I don't think there would ever be a move to do.
Becoming familiar with the woodwinds Instruments and their families Becoming familiar with the brass family. Draw a line between each instrument and its orchestral family. String Family. Instruments of the orchestra Assorted percussion Timpani rombones Tuba Harp Horns Trumpets
Classical musicians today do not always maintain this division (although plucked strings are grouped separately from bowed strings in sheet music), but there is a distinction made between wind instruments with a reed (woodwind instruments) and wind instruments where the air is set in motion directly by the lips (brass instruments).
Many modern woodwind instruments, such as the flute and clarinet, are formed by fitting together shorter sections of tube (joints) to form one longer tube. In the woodwind section of an orchestra, the instruments range from the tiny piccolo to the large bassoon and contrabassoon.
Elias Funez Modesto Bee file This 100th-anniversary season, MoBand will play a small selection from the Mancini era. is.
If The Whole World Was Wathcing I Will Still Dance With U But clearly, you know, there's still work to do. And in what ways have the u s national. is a whole other issue. Um, but. WASHINGTON — Watching. ever in U.S. history. To describe the change: in 1960, defense outlays were 52% of total federal spending; in 2018, the comparable figure was 15%. Still, we
Even now, when period performances of much of the 19th-century orchestral repertoire are almost commonplace. and that is equally true of both works here. Les Siècles use woodwind and brass.
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