Abstract
Disability simulations have taken many forms over the years. For many people, disability simulations—in which participants undertake an activity to obtain an understanding of what it would be like to have a disability—are common practice in disability-related education. Some trainers use this approach in education to increase the empathy of children without disabilities for their peers with disabilities. Others use these activities in higher education settings in which students will be working with people with disabilities in the future (e.g., occupational therapists, special educators, nurses, rehabilitation counselors). These activities may include using a wheelchair to navigate a space, completing activities while wearing a blindfold, and navigating the world with simulated hearing loss. Many people with disabilities take umbrage at the use of this approach as a means to increase understanding or awareness of the lived experience of disability (e.g., Barney, 2012; French, 1992; Kiger, 1992).
Background
Much of the research on disability awareness activities has not used empirical data (Flower et al., 2007). A meta-analysis of the disability simulation literature identified 41 articles, 61% of which did not use empirical data (Flower et al., 2007). The remaining 39% found no particularly positive educational effect but also no negative effect of using disability simulations as a means of education. Indeed, in our research, we have been unable to find many large-scale empirical studies of the impact of disability simulation on attitudes toward disability. Small-scale qualitative studies have demonstrated varying results, some positive (Leo & Goodwin, 2014) and some negative (Lalvani & Broderick, 2013), and one large-scale study of children found an increase in positive attitudes after a learning program that included disability simulation (Papaioannou et al., 2014).
Other studies have shown that, rather than developing more positive views of disability, students who participate in these activities have decidedly negative views after participation. In one study, postactivity results showed that some participants thought having a disability would be miserable or lonely (Wood, 1990). Additional studies also demonstrated an association between negative attitudes toward disability and disability simulation activities (Stamou & Padeliau, 2009; Wright, 1980). Recent studies have demonstrated that simulated blindness led participants to perceive people with that disability as less capable (Silverman et al., 2015) and that disability simulation activities increased negative attitudes but also increased empathy toward people with disabilities (Nario-Redmond et al., 2017).
Beyond the rise in negative attitudes toward disability as a result of disability simulation, many other criticisms of disability simulation have been noted (e.g., Barney, 2012; French, 1992; Kiger, 1992). One common criticism is that simulation exercises do not provide participants with an understanding of the lived experience of disability, providing perhaps an understanding of only the onset of disability (French, 1992). For instance, using a wheelchair for an hour does not provide a real understanding of the daily experiences of a person who uses a wheelchair. For many, a wheelchair is a means of mobility, whereas someone who is not accustomed to using a wheelchair may, after using one for only 1 hr, perceive it as a barrier to mobility. Similarly, the temporary nature of disability simulation (e.g., wearing a blindfold for a series of tasks, using a wheelchair for an hour) does not appropriately duplicate the often-permanent nature of disability, again distorting the alleged educational experience (French, 1992; Kiger, 1992).
Objectives
French (1992) concluded her criticism of disability simulation techniques with the sentence “Disabled people, who run disability equality training courses or devise disability equality training packs . . . never use simulation exercises” (p. 265). Yet, these exercises continue to be used in educational settings in occupational therapy and other fields around the country and world. Given that little information is available about the effect of disability simulation on attitudes—positive or negative—we aimed in this study to explore alternatives to disability simulation and examine the effect of both disability simulation and alternative disability education activities on participants’ perceptions of, and behavior toward, people with disabilities. We addressed four research questions:
What influence do personal factors (age, gender, race, student status, having a disability, and having an immediate family member with a disability) have on attitudes, affect, cognitions, and behaviors relating to disability?
Does participation in an access audit (tape measure activity) have an effect on attitudes, affect, cognitions, and behaviors relating to disability?
Does participation in a wheelchair activity have an effect on attitudes, affect, cognitions, and behaviors relating to disability?
Do students who participate in a tape measure activity and students who participate in a wheelchair activity differ in attitudes, affect, behaviors, and cognitions relating to disability?
Method
We used a matched pretest–posttest design with two interventions to compare the effects of both interventions on attitudes toward disability. Data collection for this study took place at a small college campus in New England. After institutional review board approval was obtained, data collection began. All participants provided consent before beginning the study and reconsented during the study. Participants who completed the study received a small amount of extra credit in one of their college courses.
Recruitment
Faculty teaching undergraduate courses in special education, rehabilitation services, psychology, biology, math, sports and exercise science, communication disorders, and general education were contacted with information about the study. Study procedures were explained, and faculty were asked whether they were willing to provide students with extra class credit for study participation. Faculty who agreed determined how many extra credit points they would offer and shared the researcher-composed recruitment email with their students.
Study Design
Participants completed a pretest survey online. After completing the survey, participants were able to self-schedule their intervention with options ranging from the following day to up to 2 wk from survey completion. During the in-person intervention, participants met with the researchers on campus for a 1-hr in-person session. On arrival, participants were given the informed consent form for a second time. They were then randomly assigned to one of two groups: the wheelchair activity group or the tape measure activity group. Both activities took approximately 1 hr to complete, and the activities were similar and intentionally comparable. Both activities had participants assess the same areas for accessibility but with different tools.
In both interventions, participants were given directions to an assigned building on campus. Participants were asked to walk or wheel to their assigned building and complete a series of tasks (e.g., if given directions to the library, to find a particular book on a shelf and to enter the bathroom). Participants in the tape measure group completed an access audit using a tape measure and a checklist of requirements of the Americans With Disabilities Act of 1990 (ADA; Pub. L. 101–336; i.e., height of bathroom handrails, weight of entry doors, height of bookshelves). Those in the wheelchair group completed each activity while remaining seated in the wheelchair. Both groups were asked to reflect on each portion of the activity.
Less than 1 day after completing their intervention session, participants were given a link to the posttest, which included same scales in the pretest. Once participants completed the posttest, they were asked to email the primary author their name and through which class they were recruited, to arrange for their extra credit. Asking participants to email after survey completion as opposed to submitting their names through the survey allowed the researchers to keep student names separate from their survey data.
Measures
Three surveys were used for this study, a researcher-developed demographics survey, Form B of the Attitudes Toward Disabled Persons Scale (ATDP; Yuker et al., 1960, 1970), and the Multidimensional Attitudes Scale Toward Persons With Disabilities (MAS; Findler et al., 2007), all of which were administered online.
Demographic Survey.
The demographic survey, an eight-item researcher-developed survey, asked participants about various demographic variables that may affect attitudes, affects, cognitions, or behaviors toward people with disabilities. The survey collected information on participants’ gender, race, age, student status (freshman, sophomore, junior, or senior), courses they had taken, and whether an immediate family member or the participant had a disability because these variables may affect attitude.
Attitudes Toward Disabled Persons Scale.
Form B of the ATDP is a widely used 30-question survey that measures attitudes toward people with disabilities. The ATDP has been used in many settings, including with college students (Patrick, 1987). The ATDP’s response format is a 6-point Likert scale with no neutral response option. Research has shown the ATDP to be a relatively stable and reliable (with test–retest reliability correlations of .71 and .83, alternate-forms reliability of .83 when compared with Form A of the ATDP, and split-half reliability estimates between .72 and .87; Antonak, 1980; Block, 1974; Yuker et al., 1960). Yuker et al. (1960) also demonstrated that the scale has high criterion and construct validity. The standard error of measurement for ATDP Form B is 9.31 (Yuker et al., 1970). Scores had a possible range of 30–150, with lower scores indicating more positive attitudes.
Multidimensional Attitudes Scale Toward Persons With Disabilities.
The MAS is a 47-item scale that begins with a brief vignette involving a person with a disability, to which the participant responds. This scale assesses affect, cognition, and behaviors related to disability. A principal-components analysis conducted by Findler et al. (2007) demonstrated that items on the scale load on three factors, confirming the assessment of affect (emotional response toward the person with a disability in the vignette), cognition (reported thoughts toward the person), and behavior (potential actions toward the person). Data in this study were analyzed using the three-subscale factor validated by Findler et al., which resulted in an Affect subscale (scores range from 16 to 80, with higher scores indicating more negative affect), a Cognition subscale (scores range from 10 to 50, with higher scores indicating more positive thoughts), and a Behavior subscale (scores range from 8 to 40, with lower scores indicating more negative behavioral responses). The Affect and Behavior subscales of the MAS demonstrate concurrent validity with the ATDP (Findler et al., 2007). To date, a standard error of measurement for the MAS has not been published.
Analyses
Data were analyzed using IBM SPSS Statistics for Mac (Version 22.0; IBM Corp., Armonk, NY). Data were first imported from Survey Gizmo (surveygizmo.com, Boulder, CO) and then cleaned (removing partial completions and duplicates). Two datasets were developed, the pretest dataset and the posttest dataset. Once the data were cleaned, the primary author used an SPSS function to merge the datasets on the basis of ID number (gleaned from mother’s maiden name). Data were then assessed for normality and were found to have non-normal distributions. Scores on the ATDP and the MAS subscales had multiple outliers, which indicated the need to analyze the data using nonparametric measures. The data were analyzed using Mann–Whitney U tests (Mann & Whitney, 1947), Kruskal–Wallis H tests (Kruskal, 1952), Wilcoxon signed-rank tests (Wilcoxon, 1945), and Pearson product–moment correlations (Pearson, 1901).
Results
Eighty-eight participants fully completed the pretest, intervention, and posttest. The average age of participants was approximately 20 yr, and just over half were female. Most of the sample was White. All of the participants were undergraduate students, most of whom were either freshmen or seniors. Finally, nearly 10% of the sample reported having a disability, and approximately 20% reported that they had an immediate family member with a disability (Table 1). Median pretest scores for the sample were as follows: ATDP, 110; MAS Affect, 47; MAS Cognition, 22; and MAS Behavior, 24. Posttest scores were fairly similar for both groups. These results are presented in depth in Table 2.
Participant Demographics (N = 88)
Note. M = mean; SD = standard deviation.
Pretest and Posttest Scores
Note. ATDP = Attitudes Toward Disabled Persons; MAS = Multidimensional Attitudes Scale Toward Persons With Disabilities; Mdn = median.
In addition, only 25 of the 88 participants achieved a change in scores larger than the ATDP Form B’s standard error of measurement of 9.31. For some, that change was positive, for example, improving attitudes toward people with disabilities (tape measure intervention: n = 8, 11.5 points; wheelchair intervention: n = 9, 7 points); for others, it was negative (tape measure intervention: n = 4, 5.75 points; wheelchair intervention: n = 6, 4.67 points). The standard error of measurement for the MAS has not been published.
Age had a significant impact on MAS Affect (r = −.360, p < .001) and Behavior (r = −.314, p = .001) scores. Mann–Whitney U tests (Table 3)—used on dichotomous variables—showed differences in gender on MAS Behavior scores. Post hoc analyses demonstrated that female participants (50.33) had higher MAS Behavior scores than male participants (37.18) at pretest, U = 2,466, Z = 2.404, p = .016. Kruskal–Wallis H tests (Table 4)—used on nominal data—showed that there were significant differences in MAS Behavior subscale scores based on race and student status. Post hoc comparisons for Kruskal–Wallis H tests demonstrated significant differences between freshmen (51.9) and juniors (27.59), with freshmen having higher MAS Behavior scores, χ2(4) = 3.028, p = .015. Post hoc tests showed no significant differences for race.
Results of Mann–Whitney U Tests for Research Question 1
Note. ATDP = Attitudes Toward Disabled Persons; MAS = Multidimensional Attitudes Scale Toward Persons With Disabilities.
Results of Kruskal–Wallis H tests for Research Question 1
Note. ATDP = Attitudes Toward Disabled Persons; df = degrees of freedom; MAS = Multidimensional Attitudes Scale Toward Persons With Disabilities.
Results demonstrated a statistically significant decrease in Affect scores (decrease in negative affect) from pretest to posttest for both those who participated in the tape measure activity (z = −2.918, p = .004, r = .311) and those who participated in the wheelchair activity (z = −2.347, p = .019, r = .250). Although both changes were significant, the median change was larger for those who participated in the tape measure activity (from 48 to 43) than for those who participated in the wheelchair activity (from 45 to 44).
We found no significant differences between scores on the ATDP (U = 884.0, z = −0.863, p = .339, r = .092), MAS Affect (U = 995.5, z = −0.100, p = .920, r = .011), MAS Cognition (U = 1,103.5, z = 1.145, p = .252, r = .122), and MAS Behavior (U = 822.5, z = −1.052, p = .293, r = .112). Median scores for the ATDP, MAS Affect, MAS Cognition, and MAS Behavior for participants who completed the tape measure activity and participants who completed the wheelchair activity are provided in Table 2. Given the low effect sizes, we maintain that no difference exists between interventions.
Discussion
The results from this study indicate that before any intervention, women, younger people, and freshmen (when compared with juniors) are more likely to respond to people with disabilities with negative behaviors, further adding to the contradictory information about personal demographics and attitudes toward people with disabilities (Yuker et al., 1970). Similarly, younger people have more negative affect toward people with disabilities. This finding may indicate that women, freshmen, and younger participants may benefit more from disability awareness information, but more conclusive information is needed.
Both the tape measure and the wheelchair interventions decreased negative affect toward disability (marginally improving attitudes), although in both cases these changes were relatively minor, consistent with the small amount of change demonstrated in previous research on disability simulation activities (Flower et al., 2007; Leo & Goodwin, 2014; Nario-Redmond et al., 2017; Papaioannou et al., 2014; Silverman et al., 2015). This decrease was larger for participants in the tape measure group, which may mean that the tape measure activity is a more effective way to reduce negative affect and improve attitudes toward people with disabilities. Despite this finding, we found no significant difference between students who took part in the tape measure activity and students who took part in the wheelchair activity.
Implications for Occupational Therapy Education
This study is the first to report on the impact of access audits on students’ attitudes toward people with disabilities. Although the results of this study indicate that the two interventions were equally effective and that both had a significant effect only on changing affect toward disability, with the tape measure activity resulting in a larger score change, this disability awareness activity was as effective as disability simulation. The current discourse of disability rights activists regarding the negative effects of disability simulation state that it is offensive, does not truly represent the experiences of people with disabilities, and does not appropriately address the often permanent nature of disability (Flower et al., 2007; French, 1992; Kiger, 1992). This discourse, coupled with the lack of significant difference between disability simulation and another educational activity, indicates that it is time for educators to retire disability simulation as a disability awareness activity. Educators who are using a disability simulation activity to increase disability awareness in their classes may benefit by changing to the tape measure activity.
Occupational therapy educators should therefore consider the following:
Given the discourse about disability simulation activities in disability communities and the lack of research demonstrating the efficacy of these activities, educators should no longer use them as a means of disability awareness.
If educators seek in-class activities related to disability awareness, they may assign an alternate ADA accessibility audit.
Limitations
Several limitations must be considered when drawing conclusions from this study. First, our sample size was relatively small. Although 88 participants is not an insubstantial number, it may not be sufficient to draw large conclusions. Because the data were not normally distributed, we used nonparametric tests, which, when coupled with the small sample size, means that the results had little power, and the study was unlikely to demonstrate statistically significant differences. Finally, given that the study took place at a single, fairly small institution, the sample is limited geographically, thus limiting its generalizability.
Conclusion
Given the limitations of this study and the lack of statistically significant differences, there is significant potential for further research. First, replicating this study with a larger and more representative sample may allow a better understanding of the effect of the two activities in question. Similarly, adding a third or fourth alternate disability awareness activity may provide an opportunity to find more effective means of disability awareness. Finally, occupational therapy practitioners may benefit from learning how often disability simulation is used as a disability awareness technique.
Despite its limitations, this study provides a much-needed empirical view of disability awareness activities in practice. This study is the first to compare two disability awareness activities that can be used to educate people about potential barriers related to disability, and it provides a unique view of the influence of these disability awareness techniques on students. Advocates and educators should listen to the disability community and other disability scholars and eliminate the use of disability simulation in the classroom, especially when empirical studies demonstrate that they are no more effective than alternative activities.
Footnotes
Acknowledgments
The authors report no conflicts of interest.