Investigating the scope of a Midlevel Rehabilitation Worker as perceived by Qualified Rehabilitation Professionals working at Community Level in the Cape

Town Metropolitan area.

Researchers: Karen-Marie. du Toit, Sithabile Machao, Jessica Trollip, Mawande Zide

Supervisor: Soraya Maart (MPH)

Submitted towards the degree requirements of Bachelor of Science in Physiotherapy September 2009

Acknowledgements The researchers would like to thank the following people for all their help in seeing this project to its completion: Soraya Maart, Lana van Niekerk, and Madeleine Duncan for their support and invaluable advice and knowledge. Also, to our focus group participants and key informants for their input and willing participation in this project.

Table of Contents
Acknowledgements...................................................................................................................................................................2 Table of Contents......................................................................................................................................................................3 Abstract......................................................................................................................................................................................5 Introduction...............................................................................................................................................................................6 Significance of Study................................................................................................................................................................7 Aim:................................................................................................................................................................................7 Objectives:......................................................................................................................................................................7 Methodology..............................................................................................................................................................................8 Research Design.............................................................................................................................................................8 Participants....................................................................................................................................................................8 Inclusion criteria...........................................................................................................................................................8 Exclusion criteria...........................................................................................................................................................8 Procedure.......................................................................................................................................................................8 Data Collection and Analysis..................................................................................................................................................9 Data Collection (see Appendix A)...................................................................................................................................9 Content Analysis...........................................................................................................................................................10 Constructing Categories...............................................................................................................................................10 Trustworthiness............................................................................................................................................................10 Ethical Considerations...........................................................................................................................................................11 Results......................................................................................................................................................................................11 1. Perceived need for the Midlevel Rehabilitation Worker...........................................................................................11 2. Types of tasks and duties (refer to Table 1.1-1.2).....................................................................................................11 3. Clinical Skills and Training required (refer to Table 2.1-2.2)..................................................................................13 4. Multi-skilled vs. discipline specific rehabilitation workers....................................................................................14 5. Who should be responsible for Supervision (refer to Table 3.1-3.2).........................................................................14 TABLE 1.1 KI - Scope of practice................................................................................................................................18 TABLE 1.2 FG - Scope of practice................................................................................................................................19 TABLE 2.1 KI - Basic skill and training requirements of MLRW..................................................................................20 TABLE 2.2 FG - Basic skill and training requirements of MLRW................................................................................21 TABLE 3.1 KI - Supervision..........................................................................................................................................22 TABLE 3.2 FG - Supervision........................................................................................................................................23

Discussion................................................................................................................................................................................24 Perceived need for a MLRW.........................................................................................................................................24 Types of tasks and duties..............................................................................................................................................24 Clinical Skills and Training required...........................................................................................................................25 Multi-skilled vs. Discipline-specific rehabilitation workers..........................................................................................25 Supervision of MLRWs.................................................................................................................................................26 Conclusion...............................................................................................................................................................................27 Limitations and recommendations......................................................................................................................................27 References ...............................................................................................................................................................................28 Plagiarism Declaration..........................................................................................................................................................29 Appendices...............................................................................................................................................................................30

Abstract Introduction: The Primary health care approach has been adopted by most developing countries to ensure affordable health care to all its citizens. The district health system has been identified by the Western Cape Department of Health as the vehicle for service delivery closest to the people. Community-based rehabilitation services have been identified as a key component in the decentralisation of health care. The Western Cape Department of health, as part of the Health Care 2010 strategy, is proposing the training of a midlevel rehabilitation worker (MLRW) that will be responsible for service delivery at community level. The aim of this study was to identify the scope of the midlevel rehabilitation worker as perceived by rehabilitation professionals working at community level within the Cape Town Metropolitan area. Methodology: A descriptive qualitative study design was utilised with focus group and key informant interviews. The focus group consisted of three rehabilitation professionals from physiotherapy, occupational therapy, and speech. Two professionals having significant involvement in community rehabilitation were interviewed as Key Informants. The focus group discussion and two key informant interviews were recorded and transcribed verbatim for content analysis. Results: The main outcomes revealed that all participants agreed that there was a need for a midlevel rehabilitation worker, with basic skills from speech and audiology, physiotherapy and occupational therapy who should be supervised by a multi- disciplinary professional team at community level. The person should also be able to advocate for the rights of people with disabilities, and would have some involvement in social development. Discussion: The findings of this study paralleled previous international and local studies, where the need for a MLRW was established. Previous literature explored the scope of a community rehabilitation worker, which identified the need for this worker to offer holistic rehabilitation within a community setting, echoing the results of this study. This worker would fit into the CBR philosophy as proposed by WHO. Conclusion: The study confirmed the need for a multi-skilled MLRW, who will work within the Social Model of Disability, under the supervision and training of the MDT, towards the empowerment of people with disabilities (PWD) within the community.

Keywords: Primary health care; Community Based Rehabilitation; Midlevel rehabilitation worker; Comprehensive Service Plan; Health Care 2010; qualitative study, focus groups. 5

Introduction

The Western Cape Department of Health is striving towards equity and accessibility in health service delivery for all people within the Western Cape (Meyer, 2003). The vehicle for the achievement of this vision is the decentralization of health care (Sanders & Chopra, 2001). As the health system is being reshaped to focus on primary level services and community-based care, the platform upon which rehabilitation must be delivered has expanded (Meyer, 2003). Thus policy makers, professionals and higher education institutions are currently debating the level of rehabilitation professional that should be trained to increase access to rehabilitation services at community level (Western Cape Provincial Department of Health, 2007). In the Western Cape Province, the Comprehensive Service Plan for the implementation of Health Care 2010 describes Community-Based Services (CBS) as those that complement the facility-based services by providing services within communities, empowering the community to participate actively in their healthcare. The health workers providing CBS will predominantly be generic community-based workers... (Western Cape Provincial Department of Health, 2007) The National Rehabilitation Policy (2001), acknowledges that rehabilitation services are concentrated at tertiary institutions and private service providers, and are therefore inaccessible to the majority of people, even in areas such as the Western Cape that are considered better resourced. Thus strategies to ensure affordable and accessible rehabilitation services (such as strengthening of community-based services) are being developed. In order to achieve the vision of accessible and affordable rehabilitation to all, there is renewed interest in a cadre of health worker who has been described as a mid-level worker (MLW). This worker takes on some of the functions and roles normally reserved for internationally recognised health professionals (Dovlo, 2004, p. 1-2), thus improvements in quality and accessible health services will be fully maximized (Lehmann, 2008). In South Africa, the training for the generic rehabilitation worker was over a 2 year period and produced 170 of these health workers. In 2003 however, the training program was stopped in support of a discipline specific rehabilitation worker (Hugo 2005). This allows for separate midlevel workers to be created within the separate disciplines of OT, physiotherapy and speech/audio. Reasons for making this new more specific category of health care worker included mainly the lack of communication between the different professional boards and an uncertainty about who would be responsible for their supervision (Hugo, 2005). The Community-Based Rehabilitation Workers were involved in the physical and social rehabilitation of people with disabilities as well as raising awareness of disability issues amongst families and community

members (Chappell and Johannsmeier, 2007) , focussing on the CBR philosophy of encouraging equal opportunities for people with disabilities through inclusive community development (WHO, 2008).

Methodology Focus groups can seldom be used describe an entire population`s response to specific questions. For this reason, the sample selected for focus group discussions must be representative of the target population and purposively selected to provide the best information (Dawson & Manderson, 1993). Focus group discussions are well suited for research conducted amongst people who have something in common with each other, such as working in the rehabilitative sector of health (Dawson & Manderson, 1993), and are specifically helpful when the study is aimed at exploring people's knowledge and experiences (Kitzinger, 1995).

Significance of Study

The significance of the study is based on the plans of the Department of Health of the Western Cape to develop a generic midlevel rehabilitation worker (Department of Health, 2006). The need for the cadre is based on the decentralization and therefore de-institutionalising of health care, as proposed by the Comprehensive Service Plan (Department of Health, 2006). The study aims to reflect the ideas of the professionals working at community level, the planners of rehabilitation services, and the trainers of community rehabilitation workers, to ensure that relevant rehabilitation skills are considered in the training of MLRWs and to identify the capacity in which they will work.

Aim: The main aim of the study is to identify the scope of a midlevel rehabilitation worker (MLRW) as perceived by professional rehabilitation workers. Objectives: To identify if there is a perceived need by the professionals for the development of a MLRW To identify the duties/tasks that could be done by a MLRW

To identify the clinical skills and training required by a MLRW in order to perform these tasks. To identify whether a generic-skilled rehabilitation worker would be able to perform all of the identified tasks (i.e. across the disciplines.) To identify who would be responsible for the supervision of the MLRW

Methodology Research Design The study used a descriptive design, implementing qualitative methods of data collection. The information was gathered through focus group discussions and key informant interviews. According to Creswell (1998), qualitative research is conducted when complex understanding of an issue needs to be explored.

Participants The sample consisted of three rehabilitation professionals (a physiotherapist, occupational therapist, and speech therapist) who have worked at community level. Participants were selected utilizing maximum variation sampling. Maximum variation sampling entails purposefully selecting a sample of persons that represent a wide range of experience related to the phenomenon of interest. (Maykut & Morehouse, 2000). The ideal number of participants for a focus group ranges from 3- 12 persons (Holloway, 1997 and Grudens-Schick et. al., 2004).

Inclusion criteria Qualified rehabilitation professionals working at primary or community level for more than 2 years, to adequately discuss the phenomenon of community based rehabilitation workers.

Exclusion criteria None

Procedure A pilot study was run to get an indication of the type of responses that could be elicited by the proposed questions. For convenience, four rehabilitation professionals, one from each of the 8

specified disciplines, working at Groote Schuur Hospital were invited to an hour focus group discussion held in GSH. Based on the findings, questions could be modified and improved where necessary. A focus group discussion was then used to explore the perceptions of rehabilitation professionals regarding the possible scope of skills and knowledge required by lower-skilled community rehabilitation workers. Two key informant interviews were also held in order to validate information obtained from the focus group, as well as gain further insight into the topic.

Data Collection and Analysis Data Collection (see Appendix A) Consent was gained from all participants. Two identified key informants were interviewed individually, for their expertise in community health and rehabilitation. A focus group discussion amongst rehabilitation professionals working at community level was also held, at a convenient time for all participants. Questions asked and topics explored: Is there a need for a MLRW? What the MLRW would do in terms of duties/ tasks/ work? What clinical skills they would require to perform these tasks? Who would supervise the MLRWs? Would a multi-skilled rehab worker (across the disciplines) be feasible?

All interviews and discussions were recorded on cassette tape. These were then labelled, dated and transcribed verbatim. Accuracy of transcription was then checked by at least 1 group member who had not been involved in the initial transcribing process. Inter-member checks were also conducted, by sending the transcriptions to the individual participants for verification. Any comments or queries were taken into account to ensure the transcribed data was an accurate reflection of the opinions and feelings of the participants.

Content Analysis Content analysis is an accepted method of textual investigation (Silverman, 2006), involving the building of categories (Silverman, 2006). This was the most feasible way of analysing the data due to the nature of the study objectives, which were specific and did not allow for indepth analysis. In this study, the four researchers involved matched the content of the data with the objectives of the study individually. This was done by reading through the transcriptions a number of times and highlighting relevant units of text, while making note of important points in the margins of the text. These separate lists were then compared amongst the four researchers and discussed to reach the most conclusive and readily agreed on categories. Reliability of the study was thus ensured as provision was made to monitor the degree of consistency with which instances [were] assigned to the same category by different observers. (Hammersley, 1992) (as cited by Silverman, 2006)

Constructing Categories The process of category formation involved grouping relevant units of text or codes, from the interviews under their corresponding study objective. From there correlations between different units of text could be found and broad categories to pool common ideas were established. Categories were frequently modified during the process of categorisation in response to continued interaction with the data. As Dey (1993) states the most important result of this categorisation is a set of categories which are conceptually and empirically grounded in the data. Categorisation produces a format which is convenient for further analysis (Dey, 1993) while allowing the researcher to make links between sets of data as well as enabling comparisons to be made between the created categories. (Dey, 1993)

Trustworthiness All transcriptions were checked by one, and in some instances two, group members who had not been involved in the initial transcribing process, to ensure accuracy and make corrections. Member checking was also used to ensure the accuracy of the transcriptions and thereby the credibility of the data. This was done by sending the transcriptions to the involved participants for verification. Once the data was analysed and categories documented, these categories were checked by 1 impartial colleague familiar with and /or experienced in qualitative research and the process of category generation. 10

For internal validity: The participants were also invited to comment on the conclusions that were drawn. Participants could then clarify points and validate findings. Respondent validation involves taking ones findings back to the subjects being studied. Where these people verify ones findings, it is argued, one can be more confident of their validity. (Silverman, 2006)

Ethical Considerations The study was approved by the Research Ethics Committee of the University of Cape Town (Rec Ref 110/2009). The aim, objectives, as well as the process of the study was explained to all participants, before informed consent was given. Participants were assured of their autonomy during the research process, transcription and analysis of data, and that participation was voluntary. There was no reward for their participation. They were informed that they could withdraw from the study at any stage without consequence.

Results Emerging themes

1. Perceived need for the Midlevel Rehabilitation Worker The key informants as well as the participants of the focus group were unanimous in their recognition of the need for a MLRW. Theres a lack of rehab techniques and skills and so there is definitely a need for those skilled rehab workers (KI 1) Theres just so much to do and we need many more community workers who can put systems in place (KI 2) There are not enough of us to reach everybody and the MLRW is definitely an answer (FG)

2. Types of tasks and duties (refer to Table 1.1-1.2) The Key Informants felt that MLRWs should be able to carry out basic or non-technical rehabilitation skills, such as transferring patients and walking patients in the parallel bars. The idea is that they have the basic training of physio, OT and speech (KI 1)

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The Key Informants also felt that the MLRW would do a lot of maintenance work of chronic patients (continuing treatment programmes set up by professionals), as well as screening, health promotion and prevention of ill health and disability (e.g. support groups). how to do a lot of education around prevention of impairments (KI 1) a lot of it will be screening, a lot of it will also be maintenance type of work (KI 2) KI 1 as well as the FG felt that the MLRWs should also play a role in more community related skills, such as social development, addressing stigma and addressing the social aspects of disease and disability. In agreement with key informant 2, the FG felt an element of advocacy work should also be included. theyre going to do social mobilization, community awareness (KI 1) some of the Social model of Disability issues dont get addressed at all dealing with stigma in the community that would be the ideal role, I think, of a community-based worker (FG) In contrast, KI 2 felt that the MLRWs should not be involved extensively in social development, but rather focus on the medical model of health care and play a small role in advocacy. I think your rehab worker (MLRW) will be more health orientated they will be a bit of advocacy work, but the (Community Development Worker) is more the one thats going to do your social things. (KI 2) Both the key informants and FG agreed that the MLRW must be able to know how to refer patients to Professionals or facilities when necessary. What you have to teach them is how to refer. (KI 1) knowing when to refer to be able to pick up if the client has chang(ed) slightly, or maybe progressed, and therefore change is needed in their programme. (FG) Key Informant 1 and 2 both agreed that there would be some skill limitations with these workers, and that they are not likely to be involved in the more specialised work. [MLRWs should] have a clear cut job description so that people know their scope of work, and that they shouldnt go beyond that. (KI 2) The focus group members also believed that the MLRW would have skill limitations, specifically relating to clinical skills such as managing dysphasia, as well as limited clinical reasoning.

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 [the MLRWs] wouldnt be expected to have any clinical reasoning or make differential diagnoses (FG)

3. Clinical Skills and Training required (refer to Table 2.1-2.2) The FG participants and the key informants agreed that it would be beneficial and at times essential for the MLRW to have the following characteristics: The individuals should be from that community and must be able to read and write (basic literacy). They would be at an advantage if they were previously a home based carer. it would make it easier if they came from the local community (FG) and being a home based carer is an advantage. (FG) The focus group members mentioned age as a possible prerequisite. you could make age a requirement as well...cause you need mature people for this.(FG) KI 1 expressed the need for a formal matric qualification in order to secure employment. its more for employment (KI 1) However, KI 2 expressed that Grade 10 would suffice. But at least I think at least standard 8. (KI 2) With regards to curriculum, the feeling amongst the FG participants and KI 2 was that the program should include basic medical terminology, an understanding of basic anatomy and physiology, and that a large extent of the training should be practical. Probably more than half the training should be practical, (FG) you need to have a basic knowledge of anatomy and physiology (KI 2) The FG participants expressed that training on interviewing and group skills should also be included. With regards to training, the FG felt that the MLRWs should be trained by all the rehabilitation members of the Multi-disciplinary Team. your multi-disciplinary team does regular training with them

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4. Multi-skilled vs. discipline specific rehabilitation workers The FG participants and key informants agreed that a multi-skilled rehabilitation worker would be more effective than a discipline-specific rehabilitation worker. it makes more sense to have one (multi-disciplined RW), quite honestly. (FG) it will make the supervision of a (MLRW) much easier. (FG) want a generic type of multi-skilled person so as not to bombard families withtoo many people coming in through their door. (K2) They recognised however, the challenges involved in the creation of a multi-skilled worker. the skills that somebody would have to have its quite substantial Its not an easy task asking them to do some Rehabilitation and some Development. (FG) theres no use empowering someone with the skills but theyre not using it. (K2)

5. Who should be responsible for Supervision (refer to Table 3.1-3.2) Both the FG participants and key informants felt that MLRWs need to be supervised. (Supervision)needs to be there so that your rehab worker does not work in isolation( KI 1) (You)cannot put people in a community if they do not have supervision. (FG) The MLRWs should work in an area where they can access support and expertise. This supervision and support could be offered by the multi-rehabilitation team (MRT) as well as other members of the multi-disciplinary team. the only way to do it properly is with a team-the whole professional team must be there. (FG) your supervision would be then your multi-disciplinary team (FG) All three if possible (physiotherapy, occupational therapy, speech and/or audiology). (KI 1)

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your rehab worker just needs to have...some way of communicating withwith the therapist. (KI 2) However, KI 1 and KI 2 furthermore gave a variety of persons/groups that could also supervise. you can get a social worker, a Primary Health Care nurse, a school teacher to help give them support and to help them. (KI 1) the supervision will come fromthe NGO which they are affiliated to (KI 2) The FG participants felt that the MLRWs would need weekly face-to-face supervision initially. The key informants however, stated that supervision did not always necessitate direct, face-to-face contact. they [MLRWs] are going to need lots of supervisionTheyll need weekly supervision FG access to the therapist just needs to be thereso that when the rehab worker encounters a problem there is an avenue to actually contact the professional.(KI 1) theres phone, theres e-mail, theres web cams even (KI 2)

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TABLE 1.1 KI - Scope of practice CATEGORIES SUB-CATEGORIES CODES Transfer in and out of bed Transfer on and off toilet Teach a child to walk between parallel bars Teach a mother to feed a child Hands on Skills CLINICAL DUTIES Stretch to prevent contractures Stroke: basic exercises Seating Maintenance Carrying out rehab programme, following professionals guidelines Identifying the need for assistive devices Identifying children with learning difficulties Screening for impairments Screening other Education Education around preventing impairment Disability prevention Prevention of pressure sores Social mobilisation Changing attitudes NON-CLINICAL DUTIES Addressing stigma Community awareness Running groups within the community Other Advocacy work (for people with disabilities) Mundane tasks of a professional In-home rehab Splinting Suctioning "Negative" Duties - out of scope of practice Social Aspects/development Audiology Initial Assessment Setting up rehab program Social Development Disability awareness

Screening

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TABLE 1.2 FG - Scope of practice CATEGORIES SUB-CATEGORIES MEANING UNITS Chronic condition management (exercise monitoring, maintaining ROM) How to stand a patient How to sit a patient Basic Transfers (transferring skills) How to walk with an assistive device Basic wheelchair management (how to handle, right size, referral for seating) Basic chest physio - breathing techniques, coughing Basic exercises Maintenance programs - post-treatment stroke, treatment regime CLINICAL DUTIES Screening programs for severely disabled children Hearing screening Early identification of difficulties Early detection of disability Early identification screening issues - identifying basic self-care problems Dysphasia - know signs Knowing when to refer - notice change, refer back to therapist or facility Identify when change in programme is needed Training caregivers to communicate with patients Effective communication with patients Communicating with somebody who needs an assisted communicative device, or after a stroke (language development) Dealing with stigma in the community NON-CLINICAL DUTIES Social Development Facilitating support groups - after strokes, communication difficulties mobilizing society Advocacy type work Make changes in Society - running disability awareness programs, teach family about disability issues Finding, identifying and following up on disabled people. Capacity building (heping them to develop; running groups around employment and social needs) Clinical reasoning Make differential diagnosis "Negative" Duties - out of scope of practice Seating Wheelchair training (seating) dysphasia management

Hands on Skills

Other

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TABLE 2.1 KI - Basic skill and training requirements of MLRW

CATEGORIES

SUBCATEGORIES Communication

CODES To co-ordinate with other services To seek guidance and support Be able to connect with supervision Understand scope of work Awareness of limitations (job descriptions) From that community (KI 2) Possibly from that community (KI 1) Possibly disabled / mother of disabled child (KI 1) Matric: for employment (KI 1) Standard 8 is too low (KI 1) At least a standard 8 (KI 2) Home-Based Carer (KI 2) At least a 2 year training program Certificate level Standardised Mixture of block training and practice Grouped around impairment, development work Basic training of rehab professionals (mobility, upper and lower, hearing, seeing, ADLs) Basic knowledge of anatomy and physiology

INTRINSIC SKILL REQUIREMENTS Personal

Entry Requirements

TRAINING

Programme

Curriculum

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TABLE 2.2 FG - Basic skill and training requirements of MLRW

CATEGORIES

SUB-CATEGORIES

MEANING UNITS From that community Able to read and write (basic literacy) Matric not necessary

Entry Requirements

Previously a home-based carer (an advantage, not a requirement) Multi-lingual (an advantage, not a requirement) Possible age requirement - 25? 18 year old might struggle Possibly disabled Basic nursing e.g. when a wound is infected Basic medical terminology Basic understanding of common conditions (what a stroke is, heart

TRAINING

disease, diabetes) Some anatomy and physiology, but Signs and Symptoms of various diseases are more important Interviewing skills Curriculum Group Skills How to communicate with stroke patients (aphasia) Some training related to Social work More than half the training should be practical Lots of in-service training Part of training should be in the community (train hearing screening and anatomy out of setting, the rest should be in the community) All disciplines involved in training MDT does regular training with them Trainers (MDT) Shadowing with Home Based Carers Being part of the rehab team for a length of time during training Regular, ongoing in-service training (community-specific needs)

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TABLE 3.1 KI Supervision CATEGORIES SUB-CATEGORIES Supervision is Necessary MEANING UNITS They need it Social worker, PHC nurse, school teacher CHC or clinic (outreach, support, monitoring) Variety of Persons Supervising Rehab, Non-Rehab, Organisations Continued supervision from a variety of Professionals and facilities is neccessary Set-up and purpose of Supervision NGO (supervision) OT, physio, speech as a team Professional / Therapist (referral, monitoring programme, progress) (2) Set periods Follow up Continued professions development Contact and guidance Not everyday or face-to-face: telephone, workshops Any access: phone, email, web cams, lines of communication open

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TABLE 3.2 FG Supervision CATEGORIES SUB-CATEGORIES Supervision is Necessary MEANING UNITS Worker must be in an area where they can access support and expertise Cannot put people in a community if they do not have supervision Professionals - OT and PT working at facility Multi-rehab, MDT Variety of Persons Supervising - MDT, NGOs Whole professional team involved NGOs do line managements (not therapists job), but line management could be done by MDT Initially a period of very close supervision and lots of access to all of the team members Weekly supervision Lots of support Set-up of Supervision CRWs will have a mentor within the team (forms part of job description) Ideally supervisors not attached to a facility, but rather working within a district MDRW run support groups, wit h some input from professionals every now and then

Continued supervision from the MDT and NGOs is necessary

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Discussion

Perceived need for a MLRW The results show that both the key informants and the participants perceived a need for a MLRW, which is in line with the global trend indicating a shortage of health care professionals. In both developing and developed countries a shortage of trained health care workers, and therefore declining health service delivery, has necessitated the introduction of assistant health workers as a solution (Dovlo, 2004). In 1978, the Alma-Ata Declaration on Primary Health Care (PHC) announced an inadequacy in primary health care provision under apartheid (Clarke, Dick & Lewin, 2008) and currently in South Africa, according to the Department of Health, a shortage of approximately seventy-three (73) Allied Health Professionals exists within the Cape Town Metro (Western Cape Provincial Department of Health, 2007). The participants felt that the MLWs would definitely be an answer and it is the hope that in creating these new health cadres, the shortage will be alleviated and equal access to services will be attainable within communities (Lehmann, 2008).

Types of tasks and duties Tasks and duties the MLRWs would be involved in, as identified by the focus group and key informants, are in line with the WHO CBR philosophy and pre-existing curriculums which were implemented both internationally and in South Africa. Community based rehabilitation is defined by WHO as a strategy for rehabilitation, equalization of opportunities, poverty reduction and social inclusion of people with disabilities. (ILO,UNESCO & WHO, Joint Position Paper, 2004). In 1990, a pilot training program was developed by the Institute of Urban Primary Health Care (IUPHC) where they trained community based rehabilitation workers (Rule, Lorenzo & Wolmarans, 2006). These workers were trained in community development, community-based rehabilitation, as well as social and physical rehabilitation (Chappell & Johannsmeier, 2009). The multi-skilled nature of the workers meant they could provide services including community development, such as social integration and the equalisation of opportunities as well as physical rehabilitation; including physiotherapy,

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occupational therapy and speech therapy. (Rule et al, 2006) The MLRW in providing these services, improv[es] patient access and releas[es] highly qualified staff to concentrate on treating and managing more complex conditions (Bosley, 2008, p.119 ) The limitations of the worker as reasoned by the focus group participants and the key informants, where the MLRW would not be expected to have clinical reasoning, echo the findings of studies done around physiotherapists and their PT assistants in the UK in 2001 (Ellis, 2001). The study of qualified therapists and their assistants concluded that the fundamental difference between them was their assessment skills (Ellis, 2001). Therefore it has been recommended that health care assistants should not be expected to make clinical judgements (Bosley, 2008) Another important limitation on the MLRWs as stated by the participants was the issue of specialised skills, similarly in a study conducted in the United States looking at the training and role definition of assistants, it was found that tasks the physiotherapists did not want to delegate to their assistants were those that involved complex skill and issues of safety (Parry, 1997).

Clinical Skills and Training required Literature reveals that MLRWs have had the most significant impact on communities at an individual level; this includes practical interventions as well as advice and counselling. (Chappell & Johannsmeier, 2009) The participants agreed with this stating that the MLRW should be trained to address both the social and health related challenges of the community, thus being trained to address the community members needs holistically. The FG stated that it would be an advantage if the MLRWs had initial training in home-based care. The ILO, UNESCO, and WHO support this by stating that rehabilitation as part of primary health care should train primary health care personnel on disability and rehabilitation. (Joint Position Paper, 2004)

Multi-skilled vs. Discipline-specific rehabilitation workers The FG and KIs felt that a multi-skilled MLRW would be better than a disciplinespecific rehabilitation worker in order to address the shortage of rehabilitation professionals working at community level. The MLRW was created in South Africa in the

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late 1980s to drive community based rehabilitation (CBR) and therefore deliver rehabilitation services to people with disabilities (PWDs) in various communities (Chappell & Johannsmeier, 2009). The FG expressed that in terms of their scope of practice they were restricted in the amount of work they could do in the community. This however could be related to it being costly and difficult to getting professionals to work in communities (Chappell & Johannsmeier, 2009). The FG also revealed that rehabilitation needed to move towards the social model of disability. Thus the work of the MLRW would encompass both physical and social therapy. This desire for rehabilitation to move towards the social model of disability is concurrent with the evolution of the CBR philosophy by the ILO, UNESCO, and WHO in recognising a more holistic approach to health care and thus rehabilitation (ILO, UNESCO & WHO, Joint Position Paper 2004). In this respect a multi-skilled MLRW would be better at providing holistic rehabilitation than the discipline-specific rehabilitation worker who is often confined to a facility and works within a narrow scope of practice.

Supervision of MLRWs Participants agreed it is important that the MLRWs are regularly supervised and do not work in isolation. This can be best achieved by offering support and a platform of expertise that the MLRWs can access. In a project done in Senegal to improve the supervisory skills of nurses supervising community based health workers (CBHWs), a CBHW was found to say We thought we were performing very well, but actually we were making mistakes. Supervision brought out our weaknesses and enabled us to improve (Prime II project, 2001, para. 1). According to Prime project II (2001, para. 4), worldwide studies frequently find flaws in supervision systems which are usually overburdened and understaffed. Thus participants felt that supervision would be made easier with the utilisation of the multidisciplinary team as well as lay people and NGO structures. .

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Conclusion Based on the findings of this study, all participants recognised that there is a shortage of health care (rehabilitation) professionals working at community level, and identified a need for a mid-level rehabilitation worker to address this shortage. Participants agreed that a multi-skilled MLRW would be more effective than a disciplinespecific MLRW in addressing this need. This multi-skilled worker should be equipped through training by the MDT with basic rehabilitation skills across the disciplines as well as community development skills, thus addressing the Social and Rehabilitation needs of the community. Supervision should be carried out by the multi-disciplinary team as well as the NGOs in a collaborative effort to ensure the workers are supported and involved in continued professional development. Ideally MLRWs should provide holistic care, aimed towards the empowerment of disabled people and their families within communities.

Limitations and recommendations

The process of content analysis was followed which unfortunately did not allow for indepth analysis of the participants responses. However, the questions that were asked allowed for this process to be utilised adequately. The focus group was smaller than recommended due to the withdrawal of participants at a very late stage. The researchers acknowledge the limitation of not including the voice of potential beneficiaries of community based rehabilitation services, and proposes it as a future research project.

WORD COUNT: 4511

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References

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Plagiarism Declaration

1. We know that plagiarism is a serious form of academic dishonesty. Plagiarism is using anothers work and pretending it is ones own. 2. Where we have used the words of others, we have indicated this with the use of quotation marks. 3. We have referenced all quotations and other ideas borrowed from others. 4. We have not and will not allow others to plagiarism our work. 5. This research project is our own work.

Date:

..

Signed:

K. du Toit .. J. Trollip .. S. Machao .. M. Zide

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Appendices

Appendix A

Faculty of Health Sciences Anzio Road Observatory 7925 Cape Town

Dear Colleague

Invitation to participate in a research study.

A Qualitative Study investigating the Need and Scope of a Lower-Skilled Rehabilitation Worker within the Cape Town Metropolitan Area, as Perceived by Qualified Health Professionals working at a Community Level.

The epidemics of Diseases of Lifestyle have overstretched the PHC system within the Western Cape Metropole, resulting in the need for creative ways to reach all of those who need rehabilitation services. The main aim of the research is to identify the need for, and scope of a lower-skilled rehabilitation worker that could assist with service delivery at community level. In order to gain this information we would like to you to participate in a focus group discussion with 7 other rehabilitation professionals, ranging from the 4 rehabilitation disciplines of Physiotherapy, Occupational therapy , Speech therapy and Audiology.

Your participation will be the following:

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You will be asked to attend a 90-120min focus group discussion with the other 7 participants and a facilitator at the University of Cape Town. Your transport costs will be reimbursed and refreshments will be provided. This focus group will be the forum for discussing what the participants feel the potential role of a lower-skilled rehabilitation worker could be in providing rehabilitative services at community level, and if the participants feel there is a need for such a worker.

This focus group will be recorded using a tape recorder, and transcribed for analysis. The participants will not be named, and will therefore remain anonymous. The outcomes of the study will be presented at a research conference, and will also be shared with the Department of Health.

Participants will have to sign an informed consent form as well as a commitment form to the privacy, confidentiality and anonymity of the other participants. Privacy during this study will be maintained through a high level of expected confidentiality and respect. By agreeing to participate, every participant is confirming that any information discussed during the focus groups will not be discussed with any persons not involved in the study, and will not be discussed outside the focus group. The discussion will be recorded via audiotape, stored with one of the investigators, and transcribed by a transcription company, participants will be titled PT1-PT2, OT1-OT2, ST1-ST2 AT1-AT2 for confidentiality purposes, and access and analysis of data will be available to the investigators and supervisors of the study.

Please note that while there are no major risks to participating in this study, there will also be no personal benefits. You will however gain insight into the need for the development of support rehabilitation services and into your peers ideas concerning this.

Although your participation would be greatly appreciated, you are under no obligation to participate in this study, and may withdraw at any time without any consequence.

Should you have any enquiries please contact any of the numbers given below. Thank you for taking the time to consider our request, once again, your participation will be greatly appreciated.

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Please confirm your participation by the following date: 20 February 2009.

Regards, KAREN DU TOIT (supervisor)

SITHABILE MACHAO (supervisor) JESSICA TROLLIP (supervisor) MAWANDE ZIDE (supervisor) SORAYA MAART (supervisor) LANA VAN NIEKERK (supervisor)

Jessica Trollip

Contact Number: 0824427163 Postal Address: 3 THE PEAKS 38 Heath Road Rondebosch CT 7700 E-mail Address: trljes001@uct.ac.za

Please complete the following confirmation and confidentiality form and e-mail / post a copy to the address given:

I .................................................(name) agree to participate in the above-mentioned study and will respect the confidentality, autonomy and privacy of those who participate.

SIGNED: .........................................

DATE: .......................

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