A stroke rehabilitation training program for community-based primary health care, South Africa

Background: With an increasing burden of stroke and a lack of access to rehabilitation services in rural South African settings, stroke survivors rely on untrained family caregivers for support and care. Community health workers (CHWs) support these families but have no stroke-specific training. Objectives: To describe the development of a contextually appropriate stroke training program for CHWs in the Cape Winelands District, South Africa. Method: Twenty-six health professionals and CHWs from the local primary healthcare services participated in action research over a 15-month period from September 2014 to December 2015. The groups participated in two parallel cooperative inquiry (CI) groups. The inquiry followed the cyclical steps of planning, action, observation and reflection. In this article, the planning step and how the CI groups used the first three steps of the analyse, design, develop, implement, evaluate (ADDIE) instructional design model are described. Results: The CHWs’ scope of practice, learning needs, competencies and characteristics, as well as the needs of the caregivers and stroke survivors, were identified in the analysis step. The program design consisted of 16 sessions to be delivered over 20 h. Program resources were developed with appropriate technology, language and instructional methodology. Conclusion: The program aims to equip CHWs to support family caregivers and stroke survivors in their homes as part of their generalist scope of practice. The implementation and initial evaluation will be described in a future article. Contribution: The study developed a unique training program for CHWs to support caregivers and stroke survivors in a resource-constrained, rural, middle-income country setting

Evaluation of a stroke rehabilitation training programme for community-based primary healthcare

Background: Family caregiver training is an integral part of stroke rehabilitation programmes and is associated with improved caregiver and stroke survivor outcomes. In the Cape Winelands District, a low-resourced rural community-based setting in South Africa, stroke survivors and family caregivers mostly rely on assistance from community health workers (CHWs), despite their lack of stroke-specific rehabilitation training. Objectives: To evaluate the implementation and immediate effects of a bespoke, 16 session, 21 h stroke rehabilitation training programme for CHWs to better support family caregivers. Methods: Two cooperative inquiry groups participated in participatory action research to design and develop the programme. This article reports on the implementation of this programme. Inquiry group members directly observed the training, obtained written and verbal feedback, interviewed CHWs and observed them in the community. Consensus on their learning was achieved after reflection on their experience and observations. Results: Learning of the cooperative inquiry groups was categorised into the effect on community-based care, the training programme’s design and development, how training was delivered and implications for service delivery. Community health workers empowered caregivers and stroke survivors and enabled access to care, continuity, coordination and person-centredness. The need for experiential learning and a spiral curriculum was confirmed. Therapists needed a different set of skills to deliver training. A systems approach and effective leadership were needed to enable community health workers to use their new skills. Conclusion: The stroke rehabilitation training programme demonstrated potential for integration into service delivery and equipping CHWs to support family caregivers and stroke survivors. Further evaluation of the programme’s effectiveness and scale-up is needed. Contribution: Evidence of an intervention to train CHWs to support stroke survivors and family caregivers

Community-based rehabilitation workers’ perspectives of wheelchair provision in Uganda: A qualitative study

Background: The challenges of wheelchair provision and use in less resourced settings are the focus of global efforts to enhance wheelchair service delivery. The shortage of professional wheelchair service providers in these settings necessitates the collaboration of multiple stakeholders, including community-based rehabilitation (CBR) workers, whose role needs to be further understood. Objectives: The aim of this study was to determine what CBR workers in three areas of Uganda perceived as (1) the challenges with wheelchair provision and use, (2) the factors contributing to these challenges, (3) the role they themselves can potentially play and (4) what facilitators they need to achieve this. Method: This qualitative study in the transformative paradigm comprised focus group discussions to gather perceptions from 21 CBR workers in three areas of Uganda, each with an operational wheelchair service, participant observations and field notes. Thematic analysis of data was implemented. Results: Community-based rehabilitation workers’ perceptions of challenges were similar while perceived causes of challenges differed as influenced by location, historical and current wheelchair availability and the CBR workers’ roles. Their main responsibilities included assistance in overcoming barriers to access the service, transfer of skills and knowledge related to wheelchairs, follow-up of users for wheelchair-related problem-solving, and user and community empowerment. Conclusion: Community-based rehabilitation workers can contribute in various ways to wheelchair service delivery and inclusion of wheelchair users; however, their capabilities are not consistently applied. Considering the diversity of contextual challenges, CBR workers’ range of responsive approaches, knowledge of networks and ability to work in the community make their input valuable. However, to optimise their contribution, specific planning for their training and financial needs and effective engagement in the wheelchair services delivery system are essential

Exploring the inclusion of teaching and learning on assistive products in undergraduate curricula of health sciences faculties at three South African Universities

CITATION: Visagie, S. et al. 2021. Exploring the inclusion of teaching and learning on assistive products in undergraduate curricula of health sciences faculties at three South African Universities. Disability and rehabilitation. Assistive technology, 16(7):722–729. doi:10.1080/17483107.2019.1701104The original publication is available at https://www.tandfonline.com/journals/iidt20Background: Providers must be knowledgeable on policy, systems and products to provide a person centred service and prescribe the most appropriate assistive product for each user. Aim: This study aimed to determine to what extent teaching and learning on assistive products are included in undergraduate curricula of the Health science faculties at three universities in the Western Cape Province of South Africa. Methods Data were gathered through a cross sectional survey. Fifteen programmes were approached of whom eight participated. Information on teaching on assistive products was sourced from purposively identified key informants, through e-mail questionnaires. Descriptive analysis was done. Results: A total of 104 assistive products were included in the eight programmes. Manual wheelchairs were the only product for which teaching was underscored by policy guidelines. Handheld mobility devices and wheelchairs were covered by five programmes. Teaching on assistive products for self-care, participation in domestic life, indoor and outdoor activities, employment and leisure was limited. Thirty seven products listed on the GATE List of 50 were taught by at least one of the programmes. Teaching and examination were theoretical in nature and occurred in professional silos. Clinical exposure was often incidental. For many products none of the four service delivery steps were covered. Conclusion: Assistive products were included in all the participating undergraduate programmes. The range of included products and the level of training were insufficient to prepare graduates to effectively address user’s needs. Newly appointed graduates will require early in-service training to ensure appropriate assistive product service delivery. Implications for rehabilitation: Undergraduate teaching on assistive products is provided in professional silos. Not all products on the GATE APL of 50 are included in under graduate teaching. Teaching does not always ensure a proficiency level that will support graduates to provide an independent AT service.https://www.tandfonline.com/doi/full/10.1080/17483107.2019.1701104Publishers versio

Figuring it out by yourself : perceptions of home-based care of stroke survivors, family caregivers and community health workers in a low-resourced setting, South Africa

CITATION: Scheffler, E. & Mash, R. 2020. Figuring it out by yourself : perceptions of home-based care of stroke survivors, family caregivers and community health workers in a low-resourced setting, South Africa. African Journal of Primary Health Care & Family Medicine, 12(1):a2629, doi:10.4102/phcfm.v12i1.2629.The original publication is available at https://phcfm.org/index.php/phcfmPublication of this article was funded by the Stellenbosch University Open Access FundBackground: In less resourced settings, formal rehabilitation services for stroke survivors were often absent. Stroke survivors were referred to community health workers (CHWs) who were untrained in rehabilitation. Aim: To describe the experience and perceived needs of stroke survivors, their caregivers and CHWs in a context with limited access to and support from formal rehabilitation services. Setting: The Breede Valley subdistrict, Western Cape, South Africa, a rural, less resourced setting. Methods: A descriptive exploratory qualitative study. Four focus group interviews were held with purposively selected stroke survivors and caregivers and four with CHWs. A thematic approach and the framework method were used to analyse the transcripts. Findings: A total of 41 CHWs, 21 caregivers and 26 stroke survivors participated. Four main themes and 11 sub-themes were identified. Because of the lack of knowledge, training and rehabilitation services, the main theme for all groups was having to ‘figure things out’ independently, with incontinence management being particularly challenging. Secondly was the need for emotional support for stroke survivors and caregivers. Thirdly, contextual factors such as architectural barriers and lack of assistive products negatively impacted care and function. Lastly, the organisation of health and rehabilitation services negatively impacted home-based services and professional support. Conclusions: With appropriate training, the CHWs can be pivotal in the training and support of family caregivers and stroke survivors. Care pathways and the role and scope of both CHWs and therapists in home-based stroke rehabilitation should be defined and restructured, including the links with formal services.https://phcfm.org/index.php/phcfm/article/view/2629Publisher's versio

Policy implementation in wheelchair service delivery in a rural South African setting

CITATION: Visagie, S., Scheffler, E. & Schneider, M. 2013. Policy implementation in wheelchair service delivery in a rural South African setting. African Journal of Disability, 2(1): 1-9, doi: 10.4102/ajod.v2i1.63.The original publication is available at http://www.ajod.orgBackground: Wheelchairs allow users to realise basic human rights and improved quality of life. South African and international documents guide rehabilitation service delivery and thus the provision of wheelchairs. Evidence indicates that rehabilitation policy implementation gaps exist in rural South Africa. Objectives: The aim of this article was to explore the extent to which wheelchair service delivery in a rural, remote area of South Africa was aligned with the South African National Guidelines on Provision of Assistive Devices, The United Nations Convention on the Rights of Persons with Disabilities and The World Health Organization Guidelines on Provision of Wheelchairs in Less-Resourced Settings. Method: Qualitative methods were used. Data were collected through semi-structured interviews with 22 participants who were identified through purposive sampling. Content analysis of data was preformed around the construct of wheelchair service delivery. Results: Study findings identified gaps between the guiding documents and wheelchair service delivery. Areas where gaps were identified included service aspects such as referral, assessment, prescription, user and provider training, follow up, maintenance and repair as well as management aspects such as staff support, budget and monitoring. Positive findings related to individual assessments, enthusiastic and caring staff and the provision of wheelchairs at no cost. Conclusion: The gaps in policy implementation can have a negative impact on users and the service provider. Inappropriate or no wheelchairs limit user function, participation and quality of life. In addition, an inappropriate wheelchair will have a shorter lifespan, requiring frequent repairs and replacements with cost implications for the service provider.http://www.ajod.org/index.php/ajod/article/view/63Publisher's versio

The impact of health service variables on healthcare access in a low resourced urban setting in the Western Cape, South Africa

CITATION: Scheffler, E., Visagie, S. & Schneider, M. 2015. The impact of health service variables on healthcare access in a low resourced urban setting in the Western Cape, South Africa. African Journal of Primary Health Care & Family Medicine, 7(1):1-11, doi:10.4102/phcfm.v7i1.820.The original publication is available at http://www.phcfm.orgBackground: Health care access is complex and multi-faceted and, as a basic right, equitable access and services should be available to all user groups. Objectives: The aim of this article is to explore how service delivery impacts on access to healthcare for vulnerable groups in an urban primary health care setting in South Africa. Methods: A descriptive qualitative study design was used. Data were collected through semi-structured interviews with purposively sampled participants and analysed through thematic content analysis. Results: Service delivery factors are presented against five dimensions of access according to the ACCESS Framework. From a supplier perspective, the organisation of care in the study setting resulted in available, accessible, affordable and adequate services as measured against the DistrictHealth System policies and guidelines. However, service providers experienced significant barriers in provision of services, which impacted on the quality of care, resulting in poor client and provider satisfaction and ultimately compromising acceptability of service delivery. Although users found services to be accessible, the organisation of services presented them with challenges in the domains of availability, affordability and adequacy, resulting in unmet needs, low levels of satisfaction and loss of trust. These challenges fuelled perceptions of unacceptable services. Conclusion: Well developed systems and organisation of services can create accessible, affordable and available primary healthcare services, but do not automatically translate into adequate and acceptable services. Focussing attention on how services are delivered might restore the balance between supply (services) and demand (user needs) and promote universal and equitable access.http://www.phcfm.org/index.php/phcfm/article/view/820Publisher's versio

Is any wheelchair better than no wheelchair? a Zimbabwean perspective

CITATION: Visagie, S., et al. 2015. Is any wheelchair better than no wheelchair ? a Zimbabwean perspective. African Journal of Disability, 4(1):1-10, doi:10.4102/ajod.v4i1.201.The original publication is available at http://www.ajod.orgBackground: Within a rights-based paradigm, wheelchairs are essential in the promotion of user autonomy, dignity, freedom, inclusion and participation. Objectives: This paper aimed to describe a group of Zimbabwean wheelchair users’ satisfaction with wheelchairs, wheelchair services and wheelchair function. Method: A mixed method, descriptive study was done. Quantitative data was collected from 94 consecutively sampled wheelchair users, who accessed wheelchair services at 16 clinics in five Zimbabwean provinces between October 2013 and February 2014, using the Quebec User Evaluation of Satisfaction with Assistive Technology for adults and children and Functioning Every day with a Wheelchair questionnaire. Qualitative data were collected through two focus group discussions (22 participants) and two case studies with participants purposively sampled from those who participated in the quantitative phase. Results: More than 60% of participants were dissatisfied with the following wheelchair features: durability (78.6%), weight (75.6%), ease of adjustment (69.1%), effectiveness (69.0%), safety (66.7%), reliability (66.7%), and meeting user needs (60.6%). Similarly, more than 66% of participants were dissatisfied with various services aspects: professional services (69.0%), follow-up (67.0%), and service delivery (68.3%). Although 60% of participants agreed that the wheelchair contributed to specific functions, more than 50% of participants indicated that the features of the wheelchair did not allow in- (53.2%) and outdoor (52.7%) mobility. Conclusion: Findings indicate high levels of dissatisfaction with wheelchair features and services, as well as mobility. It is recommended that policy and minimum service standards which incorporate evidence and good practice guidelines for wheelchair services and management of wheelchair donations are developed for Zimbabwe.http://www.ajod.org/index.php/ajod/article/view/201Publisher's versio

Impact of structured wheelchair services on satisfaction and function of wheelchair users in Zimbabwe

CITATION: Visagie, S., et al. 2016. Impact of structured wheelchair services on satisfaction and function of wheelchair users in Zimbabwe. African Journal of Disability, 5(1):1-11, doi:10.4102/ajod.v5i1.222.The original publication is available at http://www.ajod.orgENGLISH SUMMARY : Background: Providing wheelchairs without comprehensive support services might be detrimental to user satisfaction and function. Objectives: This paper compares wheelchair user satisfaction and function before and after implementation of comprehensive wheelchair services, based on the World Health Organization guidelines on wheelchair service provision in less resourced settings, in Zimbabwe. Method: A pre- and post-test study with a qualitative component was done. Quantitative data were collected with the Quebec User Evaluation of Satisfaction with Assistive Technology for adults and children and the ‘Functioning Every day with a Wheelchair Questionnaire’. Data were collected from 55 consecutively sampled wheelchair users, who received a new wheelchair in the study period. Qualitative data were collected through two audio recorded focus groups and two case studies and are presented through narrative examples. Results: The proportion of adult users who were satisfied significantly increased for all wheelchair and service delivery aspects (p = 0.001 - 0.008), except follow-up (p = 0.128). The same was true for children’s post-test ratings on all variables assessed (p = 0.001 - 0.04), except training in the use of the device (p = 0.052). The biggest improvement in satisfaction figures were for comfort needs (44.3%), indoor mobility (43.2%), outdoor mobility (37.2%), safe and efficient, independent operation (33.5%) and transport (31.4%). The qualitative data illustrated user satisfaction with wheelchair features and services. Conclusion: The wheelchair service programme resulted in significant positive changes in user satisfaction with the wheelchair, wheelchair services and function. It is recommended that the Zimbabwean government and partner organisations continue to support and develop wheelchair services along these guidelines.http://www.ajod.org/index.php/ajod/article/view/222Publisher's versio