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How can we overcome barriers to accessing rehabilitation for persons with disabilities in LMIC? - Evidence brief

MACTAGGART, Islay
April 2021

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Rehabilitation is described as a set of measures to optimise the functioning of individuals, and is important for wellbeing, participation and quality of life. Rehabilitation includes diagnosis, treatments, surgeries, assistive devices and therapies. Not all people who need rehabilitation are people with disabilities, and not all people with disabilities need rehabilitation. The World Health Organisation (WHO) recently estimated that 1 in 3 people globally (2.41 billion people) would benefit from rehabilitation: this number has increased nearly two thirds since 1990, due to population growth and increase in Non-Communicable Diseases (NCDs). In contrast, there are estimated to be less than 10 skilled rehabilitation practitioners per million population in Low and Middle Income Countries (LMICs), and only 5 – 15% of people in need of assistive devices are thought to have received them.

 

Evidence is reviewed and recommendations provided

German version of the Chelsea Critical Care Physical Assessment Tool (CPAx-GE): translation, cross-cultural adaptation, validity, and reliability

EGGMANN, Sabrina
VERRA, Martin L
STEFANICKI, Valentine
KINDLER, Angela
SEYLER, Daphne
HILFIKER, Roger
SCHEFOLD, Joerg C
BASTIAENEN, Caroline H G
ZANTE, Bjoern
2021

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Purpose: To translate and cross-culturally adapt the Chelsea Critical Care Physical Assessment tool from English to German (CPAx-GE) and to examine its validity and reliability.


Materials and methods: Following a forward-backward translation including an expert round table dis- cussion, the measurement properties of the CPAx-GE were explored in critically ill, mechanically ventilated adults. We investigated construct, cross-sectional, and cross-cultural validity of the CPAx-GE with other measurement instruments at pre-specified timepoints, analysed relative reliability with intraclass correl- ation coefficients (ICCs) and determined absolute agreement with the Bland–Altman plots.

 

Results: Consensus for the translated CPAx-GE was reached. Validity was excellent with >80% of the pre- specified hypotheses accepted at baseline, critical care, and hospital discharge. Interrater reliability was high (ICCs > 0.8) across all visits. Limit of agreement ranged from 2 to 2 points. Error of measurement was small, floor, and ceiling effects limited.

 

Conclusions: The CPAx-GE demonstrated excellent construct, cross-sectional, and cross-cultural validity as well as high interrater reliability in critically ill adults with prolonged mechanical ventilation at baseline, critical care, and hospital discharge. Consequently, the CPAx-GE can be assumed equal to the original and recommended in the German-speaking area to assess physical function and activity of critically ill adults across the critical care and hospital stay.

User Satisfaction with Conventional Lower-Limb Orthotic Devices: a Cross-Sectional Survey in Pakistan

Aftab, Zohaib
Zaidi, Zohaib Ahmed
Shafi, Faraz
2020

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Purpose: Persons with disabilities affecting lower-limb function use ankle- foot-orthoses (AFO) and knee-ankle-foot-orthoses (KAFO) on a regular basis. However, the effectiveness of these devices in daily use is seldom evaluated, especially in the developing world. This study aimed to evaluate user satisfaction with lower-limb orthotic devices while performing a broad spectrum of daily life activities in Pakistan, and to document the desired outcomes.

 

Method: A survey was conducted among orthotic device users in the out-patient departments of three hospitals in Lahore, Pakistan. The survey questionnaire was devised by adapting the Prosthetic Evaluation Questionnaire to suit orthotics evaluation. Fifty-four AFO and KAFO users participated in the study.

 

Results: Most users felt comfortable while walking on even surfaces with their orthoses. However, donning/doffing these, climbing stairs and performing certain routine activities were considered problematic for most people. Energy conservation was the most desired AFO feature, while the KAFO users wanted automatic knee-joint function.

 

Conclusion and Implications: Overall satisfaction with the existing lower- limb orthoses is adequate. Yet, significant improvements are needed in terms of energy efficiency and comfort while walking on different terrains. Further research is required in order to improve the functioning of the existing orthotic devices.

Effects of Biofeedback and Task-Oriented Intervention on Balance Confidence and its Relationship with Social Participation among Stroke Survivors

Pachiappan, Elumalai
2020

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Purpose: The study aimed to compare the effects of balance training on balance confidence and its relationship with social participation among clients with stroke.

 

Method: A pre- and post- experimental group design was used. Stroke survivors who met the inclusion criteria were consecutively assigned to two groups (task- oriented and biofeedback). Participants in the task-oriented group received task- oriented activities for 20 minutes and the biofeedback group received intervention in correckta (equipment used for balance training) for 20 minutes, along with conventional occupational therapy - 5 sessions per week, for 12 weeks. Balance Confidence Scale was used for measuring balance confidence, and Frenchay Activities Index (FAI) was used to measure social participation. Statistical calculations were performed with SPSS version 16.0 package. Statistical tests were carried out with the level of significance set at p≤ 0.05.

 

Results: The findings suggest that both the biofeedback and task-oriented groups showed significant improvement in balance confidence and there was no statistically significant difference between the groups. There was a moderate to good relationship between balance confidence and social participation.

 

Conclusions and Implications: There is evidence that many stroke survivors have low balance confidence. Therapists should assess the balance confidence of their clients and encourage them to participate in these beneficial interventions.

Assistive Technology Capacity Assessment (ATA-C) Survey Mongolia

Sunil Deepak
April 2020

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An Assistive Technology Capacity Assessment (ATA-C) survey in Mongolia in 2019. This survey was the first step in the effort to improve and strengthen the Assistive Technology (AT) services in the country, as part of the action following the resolution 71.8 of the World Health Assembly (WHA) in May 2018. WHO’s ATA-C survey has 4 questionnaires, these were translated and field tested in Mongolia. In collaboration with Tegsh Niigem, a Mongolian NGO, the major stakeholders involved in policy, acquisition, procurement, production and distribution of assistive products in the country were interviewed and compiled the WHO questionnaires. All together 47 persons were interviewed. This report presents the key findings from this survey.

Experiences accessing and using rehabilitation services for people with physical disabilities in Sierra Leone

AENISHANSLIN, Justine
AMARA, Abu
MAGNUSSON, Lina
April 2020

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In order to explore the experiences of persons with physical disabilities accessing and using rehabilitation services in Sierra Leone, interviews with 38 individuals with differing physical disabilities were carried out in three locations across Sierra Leone (Freetown, Bo and Makeni).

The analysis resulted in six themes:  The initial and ongoing need for rehabilitation throughout life; Challenges with the cost of rehabilitation and transportation to reach rehabilitation services; Varied experiences with rehabilitation staff; Coming to terms with disability and facing stigma; The struggles without and opportunities with rehabilitation services; Limited knowledge and availability of rehabilitation services.

Addressing barriers to affordability, access, and availability of rehabilitation and addressing knowledge gaps, attitudinal barriers and stigma towards rehabilitation and persons with disability are discussed.

 

Disability and Rehabilitation, April 2020

DOI: 10.1080/09638288.2020.1755375

The role of rehabilitation care workers in South African healthcare: A Q-methodological study

GAMIET, Shamila
ROWE, Michael
October 2019

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Background: The South African Department of Health identified the need to train a new cadre of community health worker (CHW) in the field of rehabilitation as part of their 2030 Health Plan that aims to improve primary healthcare (PHC) and community-based rehabilitation (CBR). Community health workers can be effectively utilised in CBR if their role is understood and their potential is not limited by professional protectionism and scepticism. A clear understanding of the scope of practice of a new cadre will minimise resistance by health professionals.

 

Objectives: The aim of this study was to explore rehabilitation health professionals’ perception of the role of the new cadre, called rehabilitation care workers (RCWs), in South African healthcare.

 

Methods: Q-methodology was used to gather and interpret the data. A convenient sample of 16 health professionals participated in the study. Participants ranked statements about the role of the RCWs from strongly agree to strongly disagree. Data were entered into PQMethod software program for statistical and factor analysis.

 

Results: Two factors emerged. Participants loading onto Factors 1 and 2 were of the opinion that RCWs’ role would be to strengthen PHC and CBR and to promote participation of people with disabilities (PWD) in intermediate care and community.

 

Conclusion: Rehabilitation health professionals’ positive perception of the new cadre is encouraging so that it could ensure their effective utilisation in CBR. Rehabilitation care workers were perceived as capable of enhancing the lives of PWD by ensuring inclusive development.

 

 

African Journal of Disability, Vol 8, 2019

Physical environments and community reintegration post stroke: qualitative insights from stroke clubs

BROOKFIELD, Katherine
MEAD, Gillian
2016

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This study investigated the environment’s role in community reintegration amongst persons with experience of stroke. Focus group discussions with 29 individuals recruited from community stroke clubs in Scotland revealed that stroke influenced a person’s perceptions, experience, use and enjoyment of the environment. Multiple specific (e.g. theatres, cafes) and more general (out-of-the- home) environments appeared capable of supporting community reintegration, providing settings in which individuals were able and willing to interact with others and participate in various functional, social and recreational activities. The article reflects on the study’s implications for policy and practice.

Assessment of Rehabilitation Capacity in Ghana

Christian, Asare
et al
2016

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Purpose: This study describes a cross-sectional assessment of infrastructure, human resources, and types of rehabilitation interventions provided in a sample of healthcare facilities in Ghana. The objectives were to (a) develop and pilot a questionnaire assessing rehabilitation capacity in LMICs, and (b) provide initial data regarding available rehabilitation care in rural Ghana.

 

Methods: Data was collected from a sample of rehabilitation workers at 9 facilities, comprised of 5 regional and 4 district hospitals, located in seven of the ten geographical regions of Ghana. Participants completed a modified version of the World Health Organisation's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care, adapted to reflect core indicators of rehabilitation infrastructure. Participating facilities were mailed questionnaires and agreed to subsequent site visits from the first author.

 

Results: There were several limitations associated with basic rehabilitation infrastructure. Consistent with previous research, significant human resources limitations were observed as hospital-based rehabilitation services were primarily rendered by 20 physiotherapists and 21 physiotherapy assistants across the 9 participating sites. No rehabilitation physicians were identified at any of the surveyed facilities. With regard to therapeutic interventions, management of musculoskeletal impairments was generally consistent with current evidence- based practices, whereas rehabilitative approaches for neurologic conditions were limited to physical rather than sensory-motor modalities.

 

Conclusions: For the first time there is study data which details the rehabilitation infrastructure, human resources, and interventions in Ghana. This study furthers the field through the adaptation and initial piloting of a rehabilitation assessment instrument that can be used in LMIC contexts.

 

Limitations: The questionnaire used for the study was modified from the questionnaire for assessing surgical care in resource poor countries, and has not yet been validated. Since the study was conducted in a convenience sample of rehabilitation/physiotherapy centres in Ghana, generalisability may be limited.

National guidelines on the provision of assistive technology in Papua New Guinea. Zero draft – April 2016

BRENTHALL, Lee
et al
April 2016

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The purpose of these National Guidelines for the Provision of Assistive Technologies (AT) in PNG is to provide a framework for a national standard of care in appropriate AT provision, for women, men, girls and boys with mobility, hearing and vision impairments, regardless of their age, location, ethnicity, and socio-economic background. It is hoped that these Guidelines will help ensure that users receive appropriate and affordable AT that suit their needs, daily activities and lifestyles, while satisfying minimum requirements for safety, strength and durability, and that service providers are trained in all steps of the service provision cycle.

A Transect Walk to Establish Opportunities and Challenges for Youth with Disabilities in Winterveldt, South Africa

LORENZO, T
MOTAU, J
2014

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Winterveldt was one of the 9 sites included in a national study to determine the livelihood strategies of youth with disabilities, undertaken by the Occupational Therapy Departments of 6 Universities in South Africa. Community-based rehabilitation (CBR) programmes were initiated in Winterveldt in the 1990s by non-governmental organisations and the Occupational Therapy Department at the University of Limpopo - Medical University of South Africa (MEDUNSA).

 

Purpose: This paper describes the use of a Transect Walk to identify aspects of context that contribute to the vulnerability of youth with disabilities with regard to their livelihood strategies.

 

Method: Transect Walk was employed as a participatory rapid-appraisal tool to gather data. Convenience sampling was used to identify 11 participants, including three youth with disabilities. Field notes and observations were analysed deductively for themes related to the 5 categories of livelihood assets.

 

Results: The findings describe the natural and built environment, the access to health, educational and financial services, and the social attitudes of people in this community towards youth with disabilities. The discussion uses the 5 CBR components as a framework to explore strategies for enhancing the assets of youth with disabilities, namely, empowerment, social, health, education, and livelihood.

 

Conclusions: There is significant development that could be maximised if youth with disabilities were aware of their rights and were able to access services and resources. The implication for local government is to create an inclusive environment in which youth with disabilities are able to participate in mainstream youth development opportunities.

Knowledge of, beliefs about and attitudes to disability: implications for health professionals

MASASA, T
IRWIN-CARRUTHERS, S
FAURE, M
2014

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Background: South Africa is a multicultural, multiracial and multilingual nation with many different values, traditions and cultural practices. Different belief systems may give rise to different attitudes and practices relating to disability, which may impact on rehabilitation. The purpose of this study was to investigate the knowledge, attitudes and beliefs relating to disability in three broad cultural groups in the Western Cape.

 

Method: Sixty primary caregivers were interviewed by using a knowledge, attitude and belief (KAB) survey in a structured interview format. Probability and non-probability (systematic and purposive) sampling were used. The study used both quantitative and qualitative methods.

 

Results: While caregivers from coloured and white communities generally had become acquainted with disability from an early age, caregivers in black communities often only learnt about disability following the birth of a disabled child. All caregivers had only a rather rudimentary knowledge of the causes of disability, but held positive attitudes towards people with disabilities and their integration into society. The qualitative data showed some differences in beliefs between the three groups in relation to the causes of disability and the need for rehabilitation. The data also revealed negative experiences across the groups in relation to education and the availability of transport, particularly amongst caregivers from black and coloured communities.

 

Conclusions: Health professionals need to understand the culture, values, beliefs and expectations of their clients when providing rehabilitation services within a community-based model. There appears to be a need for improved disability awareness in schools and amongst transport service providers.

Training CBR Personnel in South Africa to contribute to the Empowerment of Persons with Disabilities

RULE, S
2013

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Purpose: Recent conceptualisations of community based rehabilitation include empowerment of persons with disabilities as a key activity. This article reports on a study which explored the training of mid-level CBR workers in South Africa, with a specific focus on the ability of the course participants to address the oppression and empowerment of persons with disabilities.

 

Method: Over a three-year period, one cycle of action research was conducted in a non-government organisation that conducts mid-level CBR training in South Africa. Data collection methods included in-depth interviews with staff, students and past graduates of the course, document analysis, participatory rural appraisal techniques and two focus group discussions with the students’ clients.

 

Results: Personnel, who had been trained in CBR before the year 2003, were found to have some difficulty in explaining the social model of disability and the oppression of persons with disabilities at a cultural and structural level. It was noted that after changes were implemented in the CBR course, the students had an orientation to working with, rather than for, persons with disabilities. They began to understand the complexities of empowerment and also engaged in social action to address the oppression of persons with disabilities.

 

Conclusions: The CBR Guidelines require a new skill-mix in mid-level CBR personnel. This study illustrates a possible training approach which can contribute to the development of these skills.

The Application of ICF-based Functioning Data on Home Environment Adaptation for Persons with Disabilities

TONGSIRI, S
HAWSUTISIMA, K
2013

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Purpose: This study illustrates how the International Classification of Functioning, Disability and Health (ICF) domains and qualifiers could be used to create functioning profiles of persons with disabilities in order to plan environmental changes. The outcome of the interventions can be measured by before-and-after comparisons of these profiles.

 

Method: 33 persons with disabilities (11 each from three provinces), with an average age of 43 years, were interviewed between November 2011 and May 2012. 67% of them were male. The functioning profiles of all the subjects were used as guidelines for home environment adaptations.

 

Results: The data helped to understand the limitations of persons with disabilities and identified the areas that needed enhancement to improve their functioning. Modification lay-outs were provided for all 33 persons with disabilities.

 

Conclusion and Implications: It was demonstrated that the ICF framework could help create functioning profiles to guide modifications in the home environment. Future studies should examine whether ICF can measure actual changes that occur after the modifications.

The Role of Community Health Workers in the Mongolian CBR Programme

COMO, E
BATDULAM, T
2012

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Purpose: This article aims to present the role of community health workers in the implementation of a comprehensive CBR Programme in rural Mongolia, and to explore the main challenges that arise in this specific geographical and socio-economic context.

 

Methods: Qualitative data were collected through semi-structured interviews with CBR workers from three selected provinces; short meetings and interviews with respective provincial level CBR coordinators complemented the information acquired. Additionally, a workshop with national level CBR stakeholders was carried out in order to review and discuss the findings.

 

Results: The study highlighted a number of practical barriers (including long distances and lack of transportation, low population density, and harsh climate conditions) which constrain the work of community health workers in the areas studied. In relation to disability, the study shed light on the difficulties found by community workers in shifting from a medical approach to disability to a new approach that emphasizes prevention and rehabilitation. Exploring interviewees’ experience in the five areas of CBR (health, education, livelihood, social, empowerment) the authors found that working in the areas other than health is perceived as difficult due to insufficient training as well as objective contextual barriers.

 

Conclusions: Despite many challenges, CBR represents a significant improvement for disability action in rural Mongolia. In this context, the local community health workers are well suited and willing to act as CBR workers; nonetheless, more training and some tailoring work to adapt the Programme to the context is needed if all potential results are to be achieved.

 

Limitations: This study did not include direct observation of CBR activities or consultation of beneficiaries and other stakeholders. Their involvement and consultation would certainly improve the understanding of all the issues raised.

Improving Accessibility to Medical Services for Persons with Disabilities in Thailand

NUALNETR, N
SAKHORNKHAN, A
2012

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Purpose: This action research aimed at developing an action plan to improve the accessibility to home health care and assistive devices for persons with disabilities in a rural community, and to evaluate changes in the numbers of such persons who received appropriate home health care and assistive devices after a three-month implementation of the action plan.

 

Method: The study was conducted at a sub-district of Maha Sarakham Province, Thailand. The main beneficiaries were 99 persons with disabilities (mean age 55.4±18.7 years). Group meetings were organised for persons with disabilities, caregivers, and various community members. An action plan for improving the accessibility of persons with disabilities to home health care and assistive devices was collaboratively formulated and implemented for three months.

 

Results: The main strategy for improving accessibility was to increase the competency of village health volunteers in providing home health care and assistive devices to persons with disabilities. After the three-month action plan implementation, the number of persons with disabilities who received appropriate home health care, i.e. at least once a month, significantly increased from 33.3% to 72.2% (Chi-square test, P<0.01, 95% CI 18.5 to 59.3). The number of persons who received assistive devices suited to their disabilities also significantly increased from 33.3% to 58.3% (Chi-square test, P=0.03, 95% CI 3.5 to 46.5).

 

Conclusions: Under the supervision of physical therapists and/or other allied health professionals, the village health volunteer is likely to be a key person for improving the accessibility to home health care and assistive devices for personswith disabilities in a rural community.

 

Limitations: The study was limited to only one sub-district. No comparable areas were studied. Further, since the study recruited persons with disabilities from a rural community, applicability of the findings to persons with disabilities in an urban community should be considered judiciously.

The Community Based Rehabilitation Programme of the University of the Philippines Manila, College of Allied Medical Professions

MAGALLONA, M L M
DATANGEL, J P
2012

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Purpose: This paper reports the process of development of a CBR programme by UP Manila College of Allied Medical Professions, and its impact on the stakeholders: persons with disabilities, students and alumni, CBR workers, local leaders and the agencies involved in the programme.

 

Method: The impact of the programme was assessed through interviews, questionnaires, focus group discussions and review of secondary data and records.

 

Results: The programme results show that the condition of persons with disabilities has improved and there has been a remarkable change in their knowledge, attitudes and skills. The positive attitudes, skills and values of students were enhanced, and the CBR programme was a “character builder” for them as rehabilitation professionals. The CBR workers who participated in the programme learnt to appreciate the potential of persons with disabilities and to accept their limitations. Another key result was the pledge by local leaders to sustain CBR in their own villages.

 

Conclusions: The students and alumni reported that the CBR programme should be replicated for nation-building. The different stakeholders reported that it helped improve the quality of life of people with disabilities and contributed to community development.

Cochrane Rehabilitation

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Cochrane Rehabilitation is aimed to ensure that all rehabilitation professionals can apply Evidence Based Clinical Practice, combining the best available evidence as gathered by high quality Cochrane systematic reviews, with their own clinical expertise and the values of patients. Their vision is a world where decision makers will be able to take decisions according to the best and most appropriate evidence in this specific field. Cochrane Rehabilitation wants to improve the methods for evidence synthesis, to make them coherent with the needs of disabled people and daily clinical practice in rehabilitation

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