A Meta-Synthesis of Disability Research in Western Africa

Abstract

Most disability research is conducted in high-income countries, despite much of the world’s population living in low- and middle-income countries. Given the flexible nature of qualitative research, studies using this methodology have the potential to provide important insights into how disability is perceived across the globe. The aim of the current study was to synthesize the results of disability research in Western Africa to elucidate prominent themes and identify methodological and participant characteristics. Secondary purposes were to evaluate the quality of included studies. A total of 223 studies were included in this meta-synthesis. Findings reveal a diversity of disability-related themes and a need to increase transparency in reporting qualitative research. Implications and suggestions for future research are discussed.

Keywords

meta-synthesis descriptive review qualitative research Western Africa

Disability is conceptualized differently around the world (Morin et al., 2021); however, the preponderance of disability research originates from the United States and Europe, despite these two areas comprising <15% of the world’s population (Saxena et al., 2006). This overrepresentation of disability research in high-income countries is problematic given that there are clear differences in how disability is perceived in high- versus low- and middle-income countries (LMICs). For example, the medical model, which posits that people with disabilities suffer from inherent deficits in need of treatment or remediation (Kirby, 2017), is the prevailing view of disability in the United States as evidenced by the criteria used to diagnose disabilities outlined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). Many people from LMICs, however, perceive disability through a cultural lens, with wide variations in what constitutes a disability (Morin et al., 2021). Furthermore, people with disabilities in LMICs are often ostracized due to a different cultural understanding of the causes of disability, with many people believing that disabilities have spiritual causes (Koszela, 2013; Stone-MacDonald & Butera, 2012). As a result of this belief, infanticide is still practiced in some countries when a child is suspected of having a disability (Koszela, 2013; Rohwerder, 2018). Understanding how disability is perceived around the world has important implications for cross-cultural researchers as well as practitioners working with immigrants from LMICs. As such, it is critically important to synthesize the disability literature base in LMICs to provide a better understanding of how disability is perceived in other parts of the world and to elucidate areas for future research.

One group of LMICs that has garnered little attention is Western Africa. Western Africa has a total population of more than 419 million people and is composed of 17 countries or territories: Benin, Burkina Faso, Côte d’Ivoire, Cape Verde (Cabo Verde), Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Saint Helena, Senegal, Sierra Leone, and Togo (Worldometer, 2022). Western Africa is a heterogeneous region with a complex history, often marred by violent conflicts and civil strife (Annan, 2014). Liberia, Sierra Leone, Côte d’Ivoire, and Guinea-Bissau have each dealt with decades of inter- and intrastate conflict marked by violence and incessant killings (Annan, 2014). More recently, insurgencies in the Sahel region have affected countries such as Mali and Niger, and low-intensity conflicts have increased in countries such as Ghana and Nigeria, which have traditionally remained more stable (Annan, 2014). The inter- and intrastate conflicts have brought many of the region’s economies to the brink of collapse (Annan, 2014), creating significant inequalities between Western African countries. For example, the Gross Domestic Product (GDP) per capita ranged from a low of $509 in Sierra Leone in 2020 (The World Bank, 2022) to a high of $10,800 in Saint Helena in 2018/2019 (St. Helena Government, 2020). These inequalities likely contribute to differences in the type and amount of disability research conducted as well as how this research is interpreted.

Western Africa can be divided into three international language communities based on the colonization history of that country: (a) French speaking, (b) Portuguese speaking, and (c) English speaking. Benin, Burkina Faso, Côte d’Ivoire, Guinea, Mali, Niger, Senegal, and Togo are former French colonies; Guinea-Bissau and Cape Verde are former Portuguese colonies; Nigeria, Ghana, Sierra Leone, and Gambia are former British colonies; and Liberia was created by freed slaves who returned from the United States (Mêgnigbêto, 2013). Saint Helena is a current British possession but is considered part of Western Africa by the United Nations (United Nations Department for Economic and Social Affairs, 2019). Despite many of these countries having official languages that are international, there are also many local languages and dialects spoken (e.g., 521 languages/dialects in Nigeria, 250 in Ghana, 30 in Liberia; Time & Pryce, 2021). These differences have implications for conducting disability research and may make inter- and intracountry comparisons difficult.

Benefits of Qualitative Research and Standards of Quality

Research, broadly defined, can encompass a range of methodologies. To provide a more focused, meaningful synthesis of the literature base, it may be preferable to narrow systematic reviews to one type of methodology. Doing so allows new insights to be generated and strengthens the conclusions that are drawn (Paterson, 2001). Qualitative research is especially suited to providing insight into people’s perspectives and beliefs about a topic (Saldaña, 2021) and can be helpful when the goal is to learn about societal and cultural beliefs. Focus groups and interviews, in particular, provide an in-depth understanding of a topic and elucidate information about a cultural group’s values and perceptions (Kitzinger, 1994). Furthermore, synthesizing the results of multiple studies on a topic can provide insights into the methods used in previous studies and illuminate areas for future research. Meta-synthesis, a method of synthesizing the results of a body of qualitative studies to better understand and explain phenomena, is particularly well suited for this purpose (Walsh & Downe, 2005).

Because the results of a study are only as reliable as the methods used to collect and analyze the data, it is critically important to examine aspects of quality when synthesizing findings across studies (Walsh & Downe, 2005). Due to the flexible nature of qualitative research, it is difficult to quantify quality; however, the field has developed multiple evaluation standards that reflect the flexibility of this type of research (e.g., Kitto et al., 2008; O’Brien et al., 2014; Tracy, 2010). These standards evaluate different aspects of a study, such as the (a) importance of the research questions, (b) methodological rigor, (c) description of the procedures, and (d) ethical compliance (O’Brien et al., 2014; Tracy, 2010). This focus on quality is a positive move forward for the field because studies that meet standards for methodological rigor provide readers with more confidence in the trustworthiness of the findings (Kitto et al., 2008). Although there are multiple sets of quality standards from which to choose, this meta-synthesis evaluated studies using the Standards for Reporting Qualitative Research (SRQR; O’Brien et al., 2014) for the following reasons: (a) they have been used in prior meta-syntheses and qualitative reviews to evaluate studies (see Nakeyar et al., 2018), (b) they are an increasingly popular standard to follow when publishing qualitative research across disciplines (e.g., Rocha et al., 2017), and (c) they have been recommended as a way to promote trustworthiness of qualitative data (Thaivalappil et al., 2018). In addition, they provide specific, objective criteria with which to evaluate multiple aspects of qualitative research (e.g., title and abstract, introduction, methods, results/findings, discussion) as opposed to other standards that provide a more theoretical discussion of quality. Moreover, a review of qualitative research evidence standards identified the SRQR as a tool that (a) is applicable across all qualitative methodologies, (b) balances brevity and comprehensiveness, and (c) stands out from other tools due to the transparency and systematic process associated with its development (Majid & Vanstone, 2018). By examining included studies using the SRQR, we can better understand the transferability and trustworthiness of disability research in Western Africa.

Qualitative disability research has emerged from Western Africa as researchers have attempted to understand the experiences and perceptions of people living in LMICs and address research questions that cannot be easily translated into quantitative research (Cleland, 2017). To synthesize the disability literature base in Western Africa, we conducted a meta-synthesis to inform the field about what is currently known about disability research in Western Africa and what is yet to be investigated. By synthesizing previous findings, this study aims to provide information on how disability is perceived in this part of the world and to effectively limit saturation in overly examined topics by informing the field of which topics may be overstudied and which topics should be examined in future research. Another purpose of this review is to examine the quality of included studies to determine whether what we know about disability research in Western Africa is trustworthy. Finally, we sought to identify the countries where research was conducted to further illuminate understudied areas and inform future research. The following research questions are addressed:

Research Question 1: What are the prior topics examined (i.e., themes, disability focus, participant demographics) in disability research in Western Africa using qualitative methods (i.e., interviews and focus groups)?

Research Question 2: What methodological characteristics (i.e., methods used, facilitator role, sample size, length of interviews/focus groups, mode of interviews/focus groups, translator use, validity methods, setting, data analysis technique, and data analysis method) have been used in disability research in Western Africa?

Research Question 3: What is the methodological quality of qualitative disability research in Western Africa as measured by the Standards for Reporting Qualitative Research (O’Brien et al., 2014)?

Research Question 4: What are future directions for qualitative disability research in Western Africa?

Method

Study Identification

Search strategy

We identified studies through a comprehensive search of peer-reviewed journals and dissertations in the following databases: Academic Search Ultimate, APA PsycINFO, Education Research Complete, Education Source, ERIC, and PubMed (see “Boolean String” on Open Science Framework [OSF] for the exact Boolean string used: https://osf.io/v7fmp/). We conducted the search on June 2, 2020 (primary search) and September 3, 2020 (updated search) using the following limiters: dissertations and peer-reviewed articles. After documents were identified, we exported them to RefWorks for deduplication and then to Covidence, an online systematic review management program, for title/abstract and full-text screening.

Ancestral search

To ensure a comprehensive search, we conducted an ancestral, forward, and first author search on all documents (i.e., articles and dissertations) that were identified through the primary and updated searches by entering the title or first author of the study in Scopus, an abstract and citation database. For the ancestral search, we reviewed all studies listed in the reference list of the included documents. For the forward search, we reviewed all studies that cited the included documents. Finally, for the first author search, we reviewed all studies published by the first author of included documents. For each of these searches, studies were first identified in Scopus and then exported to RefWorks for deduplication. For studies not indexed in Scopus, we conducted a hand search of the reference list. See the document titled “PRISMA Flowchart” on OSF (https://osf.io/v7fmp/) for a flowchart depicting the number of documents retrieved at this and subsequent stages of the review.

Inclusion/exclusion criteria

We applied the following inclusion criteria at the title/abstract phase: the study was (a) written in English, (b) conducted in Africa, (c) focused on disabilities, and (d) used qualitative methodology. More specifically, our team retained studies that met the following criteria: (a) included participants with disabilities that are identified under the Individuals with Disabilities Education Improvement Act (IDEA, 2004), (b) mentioned inclusive education or inclusion of students with disabilities, (c) included participants who work with children/adults with disabilities (e.g., parents/caregivers of people with disabilities), (d) included participants who had mental health disorders, (e) described participants as using a wheelchair, having an amputation, and used other terms related to physical disabilities, or (f) referred to participants as having a generic disability. Disabilities identified under IDEA (2004) include the following: specific learning disabilities, other health impairments, autism spectrum disorder, emotional and behavior disability, speech or language impairment, deafness, hearing impairment, deaf-blindness, orthopedic impairments, intellectual disability, traumatic brain injury, multiple disability, and visual impairment. We excluded studies focused on human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), obesity, gambling addiction, drug addiction, orphan status, and phobias. Our team used the following definition of qualitative research: “The study had to use qualitative methods of data collection and analysis, as either a stand-alone study or a discrete part of a larger mixed-method study” (Noyes & Popay, 2007, p. 230). During full-text screening, we narrowed the criteria related to qualitative research to only include qualitative studies that reported focus group and/or interview data.

Title/abstract and full-text review

The search resulted in 11,193 documents after duplicates were removed (primary search = 5,377, ancestral/first author/forward search = 5,816; see “PRISMA Flowchart” on OSF: https://osf.io/v7fmp/). We evaluated the titles/abstracts of all identified documents using the previously stated inclusion criteria. If the coding team was unable to determine whether the document met inclusion criteria based on the title/abstract alone, we evaluated the full text of the article. After title/abstract screening, 8,486 articles were excluded, resulting in 2,707 articles for full-text review. As a result of full-text screening, 2,484 documents were excluded (see reasons for exclusion in “PRISMA Flowchart” on OSF: https://osf.io/v7fmp/), resulting in 223 studies retained for variable coding.

Interrater Reliability (IRR)

Prior to coding, the primary researcher (first author) trained all coders to criteria (i.e., 90% or greater reliability) on a subset of documents not included in the IRR calculations. Training consisted of providing team members with a verbal and written description of inclusion criteria, as well as examples and non-examples of documents meeting each criterion. Furthermore, team members practiced coding a subset of titles/abstracts and full texts until they achieved at least 90% reliability with the first author. The following percentage of documents was coded by two team members for IRR purposes: 64% for titles/abstract screening, 68% for full-text screening, and 44% for variable coding. When disagreements occurred, consensus was reached between the primary and the secondary coders. Interrater reliability results were as follows: 92.39% for title/abstract screening, 93.89% for full-text screening, and 96.8% for variable coding (see “Interrater Reliability” on OSF: https://osf.io/v7fmp/ for detailed IRR results). Across all variables coded, the only one that dropped below 80% was the SRQR Data Collections Standard (O’Brien et al., 2014). This was primarily due to coders disagreeing on whether the authors provided sufficient detail about their data collection methods to meet this criterion.

Qualitative Reporting Standards Coding

We used operational definitions for the SRQR described in Supplemental Digital Appendix 2 of O’Brien and colleagues (2014) to code all included studies. The SRQR is broken into 21 items that can be broadly grouped according to the following categories: title and abstract, introduction, method, results/findings, discussion, and other. The title and abstract category includes the (a) title and (b) abstract standards. The introduction category includes the (a) problem formulation and (b) research questions standards. The method category includes the following 11 standards: (a) qualitative approach and research paradigm, (b) researcher characteristics and reflexivity, (c) context, (d) sampling strategy, (e) ethical issues pertaining to human subjects, (f) data collection methods, (g) data collection instruments, (h) units of study, (i) data processing, (j) data analysis, and (k) techniques to enhance trustworthiness. The results/findings category includes the (a) synthesis and interpretation and (b) links to empirical data standards. The discussion category includes the (a) integration with prior work, implications, transferability, and contributions to the field and (b) limitations standards. Finally, the other category includes the (a) conflicts of interest and (b) funding standards. For a description of each standard, see “Variable Codes” on OSF at https://osf.io/v7fmp/.

Variable Coding

In addition to the SRQR, we coded studies according to the following variables: study location, participant characteristics, methodological characteristics, and future directions. For study location, we coded in which Western African country the study was conducted (i.e., Burkina Faso, Côte d'Ivoire, Cape Verde, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone, and Togo). For all other variable codes, see below for a detailed description of the coding categories and the document titled “Variable Codes” on OSF (https://osf.io/v7fmp/) for operational definitions of each code.

Participant characteristics

For participant characteristics, we coded gender (i.e., male, female, not specified), average age (i.e., 0–10 years old, 11–20 years old, 21–30 years old, 31–40 years old, 41–50 years old, 51–60 years old, or not specified), role (i.e., community members, education workers, government workers, healers/cultural medicine, non-governmental organizations [NGOs] or non-profit organizations, parents/caregivers, person with a disability, siblings/peers, or not specified), and disability type (i.e., attention deficit hyperactivity disorder, autism spectrum disorder, blind/visual impairment, deaf/blindness, development disability, Down syndrome, emotional and behavioral disorders, epilepsy, general term of disability, intellectual disability, learning disability, mental health disorders/neurological disability, orthopedic impairment, speech communication disorders/speech language impairment, traumatic brain injury).

Methodological characteristics

For methodological characteristics, we coded methods used (i.e., focus groups and interviews), facilitator role (i.e., community members, modern medicine workers, person with a disability, researchers/graduate students, not specified), sample size (i.e., 0–10, 11–20, 21–30, 31–40, 41–50, 51–100, 101+, not specified), length of interview/focus group (i.e., 0–30 minutes, 31–60 minutes, 61–90 minutes, 91–120 minutes, not specified), mode of interview/focus group (i.e., in person/face to face, online, telephone), translator use (i.e., yes, no, not specified), validity methods (i.e., member checking, triangulation, audit trail, disconfirming evidence, back translation, peer debriefing, thick description, prolonged engagement), setting (i.e., school, higher education/college, home, medical, community, religious area, participant workplace, technology), data analysis technique (i.e., inductive, deductive, hybrid), and data analysis method (i.e., thematic analysis, content analysis, phenomenological analysis, narrative analysis, discourse analysis, inductive analysis).

Future directions for continued study

For future directions, we coded the following variables: (a) more education, supports and training, (b) increased awareness and acceptance, (c) government policy changes, (d) increased programming and curriculum, (e) increased inclusion, (f) research in other areas and with other people, and (g) future research to quantify and confirm findings. For participant gender, we coded the exact number of participants reported within each of the gender categories. All other variables were coded categorically.

Process for Developing Codes

Codes were developed using a hybrid approach, meaning that some codes were developed a priori based on theory, whereas others were developed using an iterative, data-driven process (Fereday & Muir-Cochrane, 2006). Examples of codes developed deductively include study location, disability focus, and codes associated with participant and methodological characteristics. For example, for disability focus, categories were initially developed based on the disability categories identified in IDEA (2004), with a few exceptions. Because there are differences in definitions between high-income countries and LMICs for “multiple disabilities” and “other health impairments,” we did not include these disabilities in our coding scheme. In addition to the codes based on IDEA (2004), we created two variable codes to capture studies that defined disability more broadly, as is often the case in LMICs (see Morin et al., 2021): (a) general term of disability, and (b) mental health disorders. Finally, epilepsy was coded as its own topic due to the sizable amount of research on this disability in LMICs. Examples of codes developed inductively include article theme and future directions. For example, for the future directions variable category, we copied and pasted the authors’ suggestions for future research verbatim from the articles into the coding document. Next, two team members read through the data to develop and refine the categories until the final seven categories were established. Other coding rules were developed by the research team to establish reliability across coders. For example, if the study provided a range of time for the length of the interview or focus group (e.g., 15–25 min), then we coded the minimum length provided (e.g., 15 min) in an effort to be conservative.

Results

A total of 14,224 participants across 205 peer-reviewed articles and 18 dissertations were included in this review (see “Reference List” on OSF for a reference list of all included studies: https://osf.io/v7fmp/). Publication dates of included studies ranged from 1980 to 2020. Although the research spanned 40 years, the majority of studies reviewed (n = 199) were published in the last 10 years. Studies were conducted across 13 countries in Western Africa, with most research originating in Ghana (n = 146; 65%) and Nigeria (n = 49; 22%). A total of 11 studies were conducted in Sierra Leone (5%), six studies in Senegal (3%) and five studies in Liberia (2%). There were eight countries with three or fewer studies conducted in their respective locations (i.e., Burkina Faso, Cote d’Ivoire, Cape Verde, Guinea, Guinea-Bissau, Mali, Niger, and Togo) and four countries with no published research meeting our inclusion criteria (i.e., Benin, Gambia, Mauritania, and Saint Helena). For a coding table detailing how each study was coded for every variable, see “Final Code File” on OSF (https://osf.io/v7fmp/).

Current Status of Disability Research

Disability topics

Focus

To gain an understanding of the types of disabilities investigated, we coded studies according to disability focus (see “Disability Focus and Article Themes Table” on OSF: https://osf.io/v7fmp/). The disabilities researched most frequently were mental health disorders (n = 62; 28%), orthopedic impairments (n = 53; 24%), and blind/visual impairments (n = 50; 22%). Other disabilities commonly investigated included “disabilities” in general (n = 42; 19%), deaf/hearing impairment (n = 38; 17%), intellectual disabilities (n = 24; 11%), and epilepsy (n = 16; 7%). The remaining disability categories were discussed in fewer than 10 studies (i.e., autism spectrum disorder, emotional and behavioral disabilities, traumatic brain injury, speech-language impairment, specific learning disability, and developmental disability).

Themes

Given the comprehensive definition of disability used in this review, a total of 15 themes were identified in the included studies (see “Disability Focus and Article Themes Table” on OSF: https://osf.io/v7fmp/). The most frequently occurring themes were perspectives from people without disabilities (n = 142; 64%), perspectives from people with disabilities (n = 109; 49%), barriers for people with disabilities (n = 94; 42%), burden of having a disability/burden of caring for someone with a disability (n = 63; 28%), and inclusive education/teacher preparation (n = 49; 22%). Less frequently occurring were themes on the cost associated with having a disability or caring for someone with a disability (n = 30; 13%), medical services or health care (n = 29; 13%), traditional medicine (n = 22; 10%), violence against people with disabilities (n = 11; 5%), and sexuality (n = 9; 4%). Interestingly, only five (2%) studies focused on higher education or employment options for people with disabilities. The following themes were only represented in one study each (<1%): church, disability culture, disability grant focused, leisure pursuits, and nutrition/food security.

Participant characteristics

Collectively, females represented 38% (n = 5,397) of the sample, males represented 29% (n = 4,179) of the sample, and 33% (n = 4,648) of the participants were not described in enough detail to code their gender. When considering the age of participants, nearly three quarters (n = 162; 73%) of studies did not report this information. Of those studies that did report age, most participants were between the ages of 31 to 50 years (n = 48; 21%), with six participants between 21 and 30 years old (3%), six participants between 51 and 60 years old (3%), and one participant between 11 and 20 years old (<1%). When considering the role of the participant, half of the included studies (n = 111; 50%) included at least one person with a disability as a participant. Of the participants with other roles, most were parent/caregivers (n = 70; 31%), education workers (n = 48; 22%), modern medicine workers (n = 38; 17%), community members (n = 35; 16%), and healers/cultural medicine (n = 33; 15%). The least common roles were government workers (n = 20; 9%), NGOs/nonprofits (n = 15; 7%), and siblings/peers (n = 16; 7%). Two studies (<1%) described participants as “key informants” or did not specify the role of the participants. See “Participant Characteristics Table” on OSF (https://osf.io/v7fmp/) for a table of these results.

Methodological characteristics

Method, facilitator/interviewer role, and interview/focus group sample size

Of the 223 included studies, the primary method used was interviews (n = 163; 73%), compared with only focus groups (n = 13; 6%); however, some studies used both interviews and focus groups (n = 47; 21%). Interviews and focus groups were predominantly conducted by researchers (n = 195; 87%), with a trivial number conducted by people with other roles (i.e., modern medicine workers, community members, and people with disabilities). Interview and focus group sample sizes varied widely (see “Methodological Characteristics Table” on OSF at https://osf.io/v7fmp/), with interview sample sizes ranging from 1 to 741 participants and focus group sample sizes ranging from 5 to 263 participants. More than half of the interviews had 20 or less participants, and approximately 67% of focus groups had 50 participants or less.

Interview/focus group length, format, and translator use

Most studies (n = 118; 53%) did not specify the length of the focus group or interview. For those that did, most were between 31 and 60 min (n = 58; 26%) or 0 to 30 min (n = 36; 16%). A small number of studies had focus groups or interviews between 61 and 90 min (n = 10; 4%) with one focus group or interview lasting more than 90 min. When examining the mode of administration, the overwhelming majority of studies were conducted in a face-to-face format (n = 217; 97%), with a negligible number of studies conducted via telephone (n = 10; 4%) or online (n = 4; 2%). Some studies were conducted in multiple formats; thus, the total number exceeds 223. Most studies did not specify whether a translator was used to conduct the interviews or focus groups (n = 136; 61%). Of those that did specify translator use, most did not use a translator (n = 57; 26%). The rationale for not using a translator was that the study was conducted in the research team’s primary language (i.e., English) or a member of the research team spoke the same language as the participants. For studies that did use a translator (n = 30; 13%), the rationale for using one was to avoid linguistic barriers due to the participants speaking unknown dialects or languages (e.g., sign language). See “Methodological Characteristics Table” on OSF (https://osf.io/v7fmp/) for a table of all results pertaining to these variables.

Validity methods, setting, and data analysis techniques/types

Researchers reported using a variety of methods to ensure validity of results, with triangulation of results (n = 115; 52%), member checking (n = 67; 30%), and back translation (n = 39; 17%) being the most common. A few researchers also reported using audit trails (n = 18; 8%), disconfirming evidence (n = 10; 4%), peer debriefing (n = 7; 3%), prolonged engagement (n = 3; 1%), and thick descriptions (n = 2; 1%). No studies reported collaborating with participants. When analyzing data, most studies used an inductive approach (n = 166; 74%), whereas other studies used a hybrid approach (n = 30; 14%). Deductive approaches were used in a negligible number of studies (n = 3; 1%), and 24 studies (11%) did not detail their methods for data analysis. Furthermore, researchers described different types of data analysis, including thematic analysis (n = 132; 59%), content analysis (n = 48; 22%), inductive analysis (n = 21; 9%), phenomenological analysis (n = 18; 8%), narrative analysis (n = 3; 1%), and discourse analysis (n = 1; <1%). A total of 24 (11%) studies did not describe an analysis type (n = 24). The settings for interviews and focus groups ranged from the community (n = 57; 26%), medical settings (n = 49; 22%), schools (n = 45; 20%), participants’ homes (n = 44; 20%), participants’ workplaces (n = 18; 8%), religious areas of worship (n = 17; 8%), distance technology (n = 18; 8%), and higher education/college (n = 9; 4%).

Methodological quality

Most studies met the majority of the SRQR (O’Brien et al., 2014; see “SRQR Results Table” on OSF: https://osf.io/v7fmp/). The standards met by the most studies were (a) purpose or research question (n = 223; 100%); (b) links to empirical data (n = 222; 99%); (c) integration with prior work, implications, transferability, and contribution(s) to the field (n = 220; 99%); and (d) problem formulation (n = 220; 99%). The standards met by the least studies were (a) title (n = 25; 11%); (b) data collection methods (n = 92; 41%); (c) researcher characteristics and reflexivity (n = 93; 42%); (d) conflicts of interest (n = 103; 46%); and funding (n = 106; 48%). Remaining standards were met by at least 70% of studies.

Future Directions for Continued Study

A total of five studies did not provide any recommendations for future research. Of those that did, many studies offered multiple suggestions for future research. The recommendation most frequently mentioned was the need for more research in other areas and with other people (n = 88; 39%). More specifically, this recommendation referred to conducting research (a) across other cities and counties, (b) with a larger and more diverse participant pool, (c) to confirm findings, and (d) to provide further insight into other people’s perspectives. The second most prevalent recommendation was for an increase or improvement in treatment programs and curriculum (n = 59; 26%). This was suggested by studies that advocated for more collaboration in the medical and educational fields and in studies that advocated for an increase in treatment for all disabilities. Third, government policy change was recommended in 54 studies (24%). More specifically, studies recommended supporting more social welfare programs to better support individuals with disabilities. Fourth, researchers in 40 (18%) studies stated there was a need for increased awareness and acceptance of people with disabilities to reduce the stigma associated with disabilities. Fifth, a total of 39 (17%) studies recommended more education, professional development, training, and support for teachers, healthcare professionals, and caregivers of people with disabilities. Sixth, a total of 26 (12%) studies recommended increased inclusion of people with disabilities to facilitate accessibility to services. Finally, a total of 14 (6%) studies recommended future research to quantify the findings of their results to confirm that their observations were needed. This was in reference to validating findings from qualitative research through quantitative methods.

Discussion

The primary aim of this review was to gain a better understanding of the current status of disability research in Western Africa by examining study characteristics, methodological characteristics, study quality, and recommendations for future research. It is notable that 199 of the 223 articles reviewed were published within the last decade, demonstrating a growing interest in disability research in this area. This increase is promising as research is often linked to capacity building through professional development, dissemination of information about evidence-based practices, and access to needed interventions and services (Durkin et al., 2015). However, it is important to note that most studies were conducted in Nigeria and Ghana, indicating that many countries in Western Africa are still understudied. The preponderance of studies in these two countries may in part be due to their relative political stability (Annan, 2014) and stronger economy (The World Bank, 2022) compared to other countries in the region. When examining the disability focus of included studies, there was a stronger focus on more obvious disabilities, such as orthopedic impairments and visual/hearing impairments. This finding supports previous reviews that found disabilities that are not readily apparent based on a person’s outward appearance, such as autism spectrum disorder, were rarely studied in sub-Saharan Africa (Franz et al., 2017). Mental health disorders were the focus of the largest number of studies; however, many studies referred to individuals with this disability as being “mentally ill” or “crazy,” demonstrating the intense stigma surrounding disabilities that are understood differently in Western Africa (see Baffoe, 2013; Morin et al., 2021). Furthermore, very few studies focused on emotional and behavior disorders, autism spectrum disorder, attention deficit hyperactivity disorder, specific learning disabilities, developmental disabilities, and traumatic brain injury, indicating a lack of understanding of these types of disabilities. This finding corroborates prior research that found disabilities in Western Africa are often understood according to the dichotomous categorization of “physical” or “mental” (Morin et al., 2021), with less known about other types of disabilities. As such, it is possible that studies describing participants as “mentally ill” or “crazy” were referring to people, not with mental health disorders as they are understood in the Western world, but instead with disabilities such as autism, attention-deficit hyperactivity disorder, emotional and behavior disorders, and others that are not as well known in Western Africa.

To contextualize the results of the disability focus variable, it is important to also consider the identified themes. For example, higher education, sexuality of people with disabilities, and leisure pursuits were infrequent themes, indicating a possible lack of acceptance of people with disabilities in the community. The extremely small number of studies that focused on higher education/employment indicates that these opportunities may not be available to people with disabilities. This hypothesis is supported by the finding that the most frequently identified themes were barriers for people with disabilities and the burden and emotional stress related to having a disability or caring for someone with a disability. These results corroborate prior research that found people with disabilities living in LMICs are often ostracized and not included in society (Koszela, 2013). To ensure equitable opportunities for people with disabilities, it is critical that efforts focus on educating the community about disabilities to promote inclusion and acceptance of these individuals.

One of the most important recommendations from this review is to increase transparency across all aspects of studies, specifically in the method and results sections. Many studies were missing critical details, which diminishes transferability (or external validity in quantitative terms) as readers are not provided with important participant demographic characteristics or methodological details. For example, there was an alarming number of studies that did not specify (a) the average age of participants, (b) the gender of participants, (c) whether participants were compensated, (d) the length of interviews or focus groups, and (e) whether a translator was used. Knowing the average age and gender of participants allows readers to determine if the sample is representative of the population and to make important determinations about whether the gender or age of participants may have influenced responses. Furthermore, having information about whether participants were compensated informs the reader about any potential bias or motivation from responders. In addition, providing information on the length of interviews or focus groups promotes replicability and transparency. Finally, explicitly stating whether a translator was used provides the reader with important information that helps contextualize the findings. For example, if a translator was not used, it can create questions about the truthfulness of the results given language differences (Van Nes et al., 2010).

This review investigated the methodological quality of qualitative disability research in Western Africa through the SRQR (O’Brien et al., 2014). Transparency was lacking in many studies. For example, less than half of the included studies met the researcher characteristics and reflexivity standard, meaning that they did not disclose their implicit bias. Qualitative research is a personal process that requires researchers to interpret results according to their own worldview; as such, it is imperative for researchers to disclose their biases to help readers interpret the results to promote trustworthiness of the data (Shaw, 2003). Furthermore, few studies met the data collection standard, meaning that they failed to provide specific details on when data collection occurred. Given that health crises and political conflicts (civil war, Ebola outbreaks, COVID-19, etc.) can have dramatic effects on participants, providing details on when studies occurred can provide important contextual information to help interpret the results. Finally, less than half of included studies disclosed conflicts of interest and funding for research, two variables that have the potential to drastically impact researcher bias. As such, it is crucial for researchers to disclose this information so readers can better understand the factors that may influence researchers’ motivation for engaging in research (Wiles et al., 2006).

In addition to the standards of quality outlined in the SRQR (O’Brien et al., 2014), we investigated whether authors of included studies used techniques to enhance the credibility and trustworthiness of their results. The results were disappointing and indicated a need for increased rigor. For example, a negligible number of studies reported using strategies such as prolonged engagement, audit trails, thick descriptions, and disconfirming evidence, all of which are important strategies for enhancing the credibility and trustworthiness of results. Although prolonged engagement is typically associated with ethnography due to the common belief that this strategy only means spending extended time in the field, it can also be applicable to interview studies when researchers conduct multiple, in-depth interviews (Brantlinger et al., 2005) and spend time learning about the culture and context of the topic under investigation (Creswell & Poth, 2018). Doing so helps the researcher achieve a deep understanding of the topic being investigated and lends credibility to the study by giving readers confidence in the conclusions. Furthermore, audit trails, which provide documentation of research decisions and activities (Tracy, 2010), are an important strategy to employ in interview and focus group studies because they help substantiate claims of prolonged engagement. One example of how audit trails might be used in this type of research includes keeping track of specific times and dates the researcher spent interviewing different participants through a participant or research log (Brantlinger et al., 2005). Using audit trails lends credibility to the study by providing readers with confidence that the claims proposed by the researcher were dependable and based on sufficient evidence.

Including thick, detailed descriptions by reporting sufficient quotes is another important strategy to enhance credibility and trustworthiness by providing evidence to support the interpretations and conclusions made by researchers (Brantlinger et al., 2005). Similarly, searching for and using disconfirming evidence lends credibility to the study by demonstrating the researcher is not presenting a biased view of the data but is rather actively searching for outliers or evidence that is inconsistent with the identified themes (Brantlinger et al., 2005). In interview or focus group studies, this may look like the researcher searching for and presenting participant quotes that are inconsistent with the majority of the data or that disconfirm identified themes. Finally, member checks are also important to include in the interview and focus group studies. Although member checks was a strategy used more frequently than the ones previously discussed, it was still used in less than one-third of included studies. Member checks can involve either (a) taking transcriptions to participants prior to analysis to review and confirm the accuracy (or inaccuracy) of the transcription or (b) taking the analyses and interpretations of data back to participants to review prior to publication for validation of the conclusions drawn by the researcher (Brantlinger et al., 2005). These are important to include not only to give readers confidence that the results are credible but also to give researchers new insights into what participants find meaningful (Tracy, 2010). Although it is possible that researchers did include these strategies and just did not report or describe their use, the low frequency that they were reported in manuscripts is problematic and points to a need for improvement in either reporting practices and/or methodological rigor of qualitative studies.

Limitations

There are some limitations that should be considered when evaluating the results. First, the research team coded disabilities based on Western definitions, which may have excluded some conditions that are considered disabilities by people living in LMICs. For example, we did not include studies that focused on diseases (e.g., HIV/AIDS, malaria, etc.) despite some community members categorizing these as disabilities (Morin et al., 2021). Second, although our team attempted to measure the quality of included studies using an accepted and widely used set of standards, quality is difficult to quantify in any methodology, particularly in qualitative research. Qualitative studies are unique, ever-evolving, and often subjective in their interpretations. As such, it may be more desirable to use multiple methods of evaluating quality as opposed to a single method as was used in this study (Chowdhury, 2015). Third, we used a conservative coding process to prevent the inflation of some variables. For example, if a range of time was given for the length of interviews or focus groups, the research team coded the minimum value reported. Consequently, results for some variables may not be exact.

Future Directions

The results of this review highlighted several directions for future research. First, more disability research is needed throughout Western Africa, but especially in countries other than Ghana and Nigeria. Most of what we know about disabilities originates from research conducted in high-income countries, which is problematic because the viewpoints of people with different cultural backgrounds are not represented in most disability research, potentially contributing to an incomplete and biased understanding of disability (Durkin et al., 2015). Qualitative research, in particular, is needed to reveal important cultural and social differences in how disability is understood and perceived by people living in LMICs. Second, it is important to investigate how people from LMICs understand and perceive disabilities that are not readily apparent by a person’s outward appearance, such as autism, learning disabilities, and emotional and behavioral disorders. Very few studies in our review focused on these disabilities and prior research indicate this may be due to people from LMICs viewing people who have characteristics of these disabilities as being spiritually possessed rather than having a disability as it is understood in the United States (Morin et al., 2021). Asking people living in LMICs about their beliefs regarding these types of disabilities can provide valuable insight into how disability is perceived around the world and provide information on what kinds of knowledge mobilization efforts are needed to disseminate information about the causes of disability, thereby reducing stigma. A final area for future research is determining how to increase the rigor of qualitative research, particularly as it pertains to disability research. Very few studies in this review used strategies to enhance the credibility and trustworthiness of their findings. Although there are many possible methods for increasing rigor, including providing better training for qualitative researchers and making professional development workshops focused on qualitative methodology more accessible, the question of how to most effectively increase rigor in qualitative research is an empirical one that can be best answered by future research.

Conclusion

Through this review, we sought to develop a deeper understanding of disability research in Western Africa by providing information on how disability is perceived in this part of the world and by informing the field on which topics should be examined in future research. The results revealed a need to invest in more rigorous qualitative research throughout the region, particularly as it pertains to disabilities that are not readily apparent by a person’s outward appearance. Furthermore, there is a strong need to recruit and prepare more researchers who (a) conduct rigorous qualitative research, (b) collect deep, rich data that supports a close analysis of current life in Western Africa as it pertains to disabilities, and (c) use strategies to increase the trustworthiness and credibility of their analyses. Through these efforts, we can continue to learn more about disabilities in Western Africa and come closer to closing the knowledge gap between LMICs and high-income countries.

Footnotes

Acknowledgements

The authors would like to thank Dr. Sara Kangas for her helpful comments on earlier versions of this manuscript, and Dr. Bill Whitney and Mr. Khanjan Mehta for their support of the project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This work was supported by an Inquiry to Impact Project Initiation grant from the Office of Creative Inquiry at Lehigh University.

ORCID iDs

Alyssa M. Blasko

Kristi L. Morin

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