Assistive technologies for visual and hearing impairments offered to medical students in Brazil

Introduction: Assistive technologies (AT) are products, equipment, devices, resources, methodologies and strategies that can be used in education to promote autonomous learning and academic success for students who have some type of disability. Objective: The objective was to analyze the AT available in medical courses in Brazil to support medical students with hearing and/or visual impairment. Methods: This is a descriptive study that used data from undergraduate medical courses participating in the Higher Education Census coordinated by Anísio Teixeira National Institute of Educational Studies and Research (Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira, INEP), in 2018. AT for students with hearing and/or visual impairment that were available in medical courses were evaluated considering the characteristics of the institution, such as the type of administration (public versus private), location (capital versus interior) and the year the course started (from the year 2000 versus before year 2000). Results: In 2018, there were 323 active medical courses in Brazil. Most of them (90%) confirmed the offer of at least one type of AT. The discipline of Brazilian Sign Language (LIBRAS, Linguagem Brasileira de Sinais) was the most frequently offered AT (80%) and tactile material was the least offered AT (32%). There was greater comprehensiveness of AT supply for medical students in courses with a private administration, compared to the public ones. The location and the year the course started did not influence the provision of AT in Brazil. The courses showed better AT comprehensiveness to support students with hearing impairment than those with visual impairment. Conclusion: Most medical courses supply AT for people with visual and/or hearing impairments who are medical students, but incompletely. Although the location of the course and the length of time that the course has been active did not influence AT provision, the study revealed inequalities. Medical students with visual and/or hearing impairments have access to assistive technologies especially in courses with private administration, adding more barriers to their financial possibilities, which are already sufficiently affected by the fact that they have to meet the essential needs common to people living with disabilities.


INTRODUCTION
Assistive technologies (AT) are products, equipment, devices, resources, methodologies, strategies, practices and services used to promote functionality and increase autonomy, independence, quality of life and social inclusion of people with disabilities (PWD) 1 . The use of AT in education is essential for the development and academic success of students who are PWD, particularly in relation to meeting their needs in the school environment and promoting empowerment and equal opportunities 2 .
Health professionals have little training to address health issues of PWD 3 . For Meeks et. al. 3 , AT are important to remove the barriers that challenge the training of more experienced doctors in this field, who know more intimately the difficulties faced by PWD and who have a greater understanding of social and biomedical problems related to disabilities.
In Brazil, several inclusive public policies have been developed for PWD, increasing access to regular education and providing a beneficial effect of increasing the number of PWD in higher education 4 . In the United States, considering only medical students, there was a 2.7% to 4.9% increase in PWD students enrolled in US medical schools from 2016 to 2019 5 . The growth trend in PWD enrollment in medical schools is a scenario that demands adaptation of educational institutions to the needs of the students.
Regarding physicians with disabilities, a national campaign conducted by the Federal Council of Medicine (CFM, Conselho Federal de Medicina) sought to estimate their number and establish the need for adjustments to the work environment 6 . In the first five months, the institution received 247 records and the physicians stated they had hearing impairment (18%), visual impairment (17%), and some did not specify the type (11%), whereas 23% of the total number reported that the disability was of congenital origin 6 .
Physicians who are PWD can influence the quality of care for other PWD, who are also patients, not only by experiencing and understanding the problems and barriers faced by both 7 but, above all, by symbolizing the reality of these people, which can therefore be experienced by their colleagues 8 . However, there is little information on the provision and comprehensiveness of medical courses regarding the supply of technical help to medical students who have some type of disability in Brazil. To increase the understanding of the scenario that involves the training of physicians who are PWD, the present study aimed to analyze the AT supply to support medical students with hearing and/or visual impairment available in medical courses in Brazil.

METHODS
This is a descriptive study that used data from the Higher Education Census in Brazil, which are managed by

Data analysis
The study included a descriptive analysis and presentation of absolute and relative frequencies. Statistical analysis was performed by comparing proportions and applying the chi-square statistical test, considering an alpha error of 5%.

Ethical aspects
The study follows the recommendations for research involving human beings and was conducted with data publicly available via web, without any identification of the research available in more than 50% of their medical courses. Figure 1 summarizes the provision of AT in medical courses according to the Federative Unit.
In Brazil as a whole, the frequency of AT supply was higher in private courses compared to public ones, with a statistically significant difference in the four different sets of comprehensiveness of AT supply analyzed. The worst scenario was the lack of technologies for visual impairment only in almost 50% of public courses in the country. The comparison of the frequencies of AT supply by macroregion reproduces the pattern of lack of supply prevalent in public courses ( Table 1).
The location of the course in the capital or in the interior of the state did not influence the offer of ATs in the country. Exceptions were found only in the Southeast Region (all AT) and in the Midwest Region (AT for visual impairment) ( Table 2).
The most recent authorization (from the year 2000) for the beginning of a medical course operation, compared to the

DISCUSSION
This study focused on AT used in higher education in Brazil and showed that most medical courses supply AT for people with visual and/or hearing impairments who attend these courses in the country. Although the location and time since the beginning of the course operation did not influence the provision of AT, the study revealed some inequalities. Medical students with visual and/or hearing impairment find support AT especially in the private courses, adding more barriers to their financial possibilities, which are already sufficiently affected by the fact that they have to meet the essential needs common to people living with disabilities.
The predominance of AT in private medical schools raises the suspicion that the same may be being experienced in other higher education courses in the country. In fact, the findings that were found in medical courses reinforces the scenario of exclusion experienced by PWD and has implications for the gains that PWD could attain with the affirmative policies that have been implemented in Brazil. A global analysis of data from 2018 showed that the number of students with disabilities enrolled in private HEI was almost two-fold those who studied in public HEI in Brazil 11 . This picture constitutes an environment of inequality that penalizes students with disabilities, who in addition to having to overcome, throughout their lifetime, several factors that limit access to higher education, add financial commitments that need to be paid for in order to acquire professional training. Considering this context of difficulties, education loses part of its democratizing and inclusive function, since the existence of obstacles, such as obtaining funds to pay for tuition is not a simple option but almost an obligation for these people.
In light of the ATs evaluated by Inep, the states of Santa Catarina, Rio Grande do Norte, and Acre show greater supply wholeness, since all the different AT are present in more than 50% of the courses in these Federative Units. Overall, the courses seem better equipped to accommodate students with reduced hearing or deafness than those with reduced vision or blindness. In India, an analysis involving 250 students and investigating 42 different types of AT to improve vision showed that sound/touch-based technologies (talking watch, Braille typewriter, audio format) and vision-based technologies (optical magnifiers, electronic magnifiers, large keyboard for computer) were the ones most often requested by the students 12 . The most common access barriers found in India were the lack of availability of AT in schools and the lack of financial resources to purchase AT by the students themselves.
The AT from information and communication technology groups are the most sophisticated ones and continue to evolve rapidly 13 . This group includes hardware and software, modified keyboards, special monitors, Braille printers and Braille lines 13 . Although they are AT that facilitate the simultaneous digital inclusion of students who have visual and/or hearing impairments, their distribution in public medical schools in Brazil is far from meeting academic needs and adapting to affirmative inclusion policies for PWD.
A survey carried out in public schools in São Paulo showed that some teachers do not use technologies that can be used by students with visual impairment, despite of them stating that such tools are essential in schools 14 .
Several reasons are mentioned for not using these resources, such as the lack of preparation for the management of AT in the regular course program, the absence of more specific programs for students with visual impairment, the lack of information aimed at teachers and students about available AT in the courses, in addition to the disbelief of PWD with visual impairment about their own ability to use such resources. In the educational environment, living with human diversity is a reality. If the focus is the inclusive education, with the teacher playing the central role of mediator of the teaching-learning process, it is necessary to remove pedagogical barriers 15 . In this context, the technical training of teachers and the promotion of attitudinal accessibility are fundamental and characterized by the elimination of prejudices, stigmas, stereotypes and discrimination 16 .
Although medical courses in Brazil seem to be more adapted to welcome students with reduced hearing or deafness, these people demand even more attention when entering the clinical phase of the course. Authors warn that the acts of listening to the sounds of the heart, lungs, intestines, as well as verbal communication with the use of surgical masks and over the phone are part of this stage of training and constitute challenges to be overcome by these students 17 . They add that common environmental noises can make communication with clinicians, residents, interns and, especially with patients, difficult. Bearing in mind that these students have their rights guaranteed by law 1 , these needs must be duly met by the managers of medical education in Brazil.
The degree of comprehensiveness of medical courses to welcome students with disabilities should be public and easily known to all interested parties. That, in addition to facilitating choices, would give the student the right to confidentiality about personal issues that may determine future directions in the teaching-learning process, and above all, would keep the focus on what the courses supply and not on the characteristics of individuals with disabilities, who would be spared from making personal disclosures prematurely. The need to establish a relationship of professionalism and impersonality between students with disabilities and the HEI is highlighted 18  'competence-based' , 'problem-based' , 'traditional' , etc., the course pedagogical project needs to recognize that the medical school has a commitment with PWD and that the student who has a disability is a reality present in the student body, requiring ways of inclusion/integration, as well as the preparation of the environment, but above all, of the teachers.
The effort must be based on meeting the individual needs of each student, who can never be seen as incapable, but only requiring adaptations that put them under the same conditions as the other students. Such an example was experienced at the Faculty of Medicine of Itajubá 23 . The adaptation covered the discipline of histology, adopted some specific technologies and met the needs of a student with congenital dyschromatopsia (color blindness), who could not correctly differentiate the shades of purple and pink, common in the discipline practices. The Association of American Medical Colleges (AAMC) highlights that the color combinations that a colorblind person has the most difficulty to differentiate are red/green, followed by blue/green and blue/yellow, and it is necessary to identify the problem early to prevent errors caused by poor color perception. This study has some limitations. Although the Inep investment to guarantee that the quality of the census data is high, some inconsistencies may have influenced our results.
Such is the case of the under-or overestimation of measures as a result of administratively collected data, without the intention of research. It is also important to acknowledge that the quality of the data collection process from the school and their report to Inep to feed the census platform depends on the commitment and involvement of the people responsible for carrying out the work at the HEI. However, Inep has invested in the quality of the provided information and reports on methodologies to deal with the Census have been published and show the commitment of institutional researchers to the Higher Education Census in Brazil 24 . The workflow includes the offer of training at Inep headquarters for the enrolled institutional researcher who performs the local and decentralized data collection. Finally, it is also worth noting that the fact that the HEI informs that it has AT does not mean that the technology is really accessible to the student who needs it. Bearing these limitations in mind, we believe that the study discloses a profile of possibilities for AT provision by medical courses and, therefore, making possible a judgment on the part of students with disabilities who manage to break through barriers and attend a medical school in Brazil.

CONCLUSION
Assistive technologies are offered in most medical courses in Brazil, but in an incomplete and unequal way. Private courses are better equipped than public courses, especially regarding the provision of AT that are simultaneously used by students with hearing impairment, as well as by those with visual impairment. Despite the legal apparatus supporting PWD, the fact that assistive technologies are more frequently found in private medical schools imposes an additional burden on students who, because they are PWD, have certainly invested a large part of their resources to reach higher education and will need to continue investing to become physicians.

AUTHORS' CONTRIBUTION
The authors contributed equally to the phases of study design, analysis and interpretation of results and the writing of the manuscript. The authors are responsible for the study content and have approved the final version that has been submitted for publication.