Harry Finkenflügel

Community-based rehabilitation: opportunity and challenge.

Community-based rehabilitation (CBR) is the main way in which disabled people in most of the world have any chance of accessing rehabilitation services. CBR was first promoted by WHO in the mid-1970s to address the shortage of rehabilitation assistance by providing services in the community with use of local resources. The strategy drew on the principles of primary health care, accepted international rehabilitation practices of the time, and also existing local practices.

The use of classification models in the evaluation of CBR programmes

Classification models for community-based rehabilitation (CBR) create conceptual order in the many types of rehabilitation programmes that exist in developing countries. Several models have been developed but none of the models appears to be widely accepted or being used in the evaluation process. Purpose. To review classification models and assess its usability. Methods. Literature review. Results. Sixteen documents were found describing 11 different models. These models vary from simply listing different types of CBR to multidimensional configurations encircling principles, methods and outcomes of CBR. The models are only incidentally used in the evaluation of CBR programmes. The more recent models have been used to develop, select and group indicators. Conclusions. Classification models can indeed structure the evaluation and comparison of CBR programs that are, by nature, very different from each other. Indicators can be developed within a theoretical framework provided by the classification model. In order to be widely accepted the models should be made less complex and focus on outcomes that are meaningful for the people involved in the evaluation as well as for policymakers and researchers.

Patient views on determinants of compliance with tuberculosis treatment in the Eastern Cape, South Africa: An application of Q-methodology

AbstractBackground: Tuberculosis (TB) constitutes one-quarter of all avoidable deaths in developing countries. In the Eastern Cape, South Africa, TB is a public health problem of epidemic proportion. Poor compliance and frequent interruption to treatment are associated with increased transmission rates, morbidity, and costs to TB control programs. This study explored determinants of (non-)compliance from the patients’ perspective. Methods: Semi-structured interviews were conducted with patients (33 treatment compliers and 34 treatment non-compliers) and 14 community health workers from local community clinics and the hospital in the township of Grahamstown, Eastern Cape, South Africa. Q-methodology was used. Patients rank ordered 32 opinion statements describing determinants of treatment compliance from the TB adherence model. By-person factor analysis was used to explore patterns in the rankings of statements by compliers and non-compliers. These patterns were interpreted and described as patient views on determinants of compliance with treatment. Patients and community health workers selected the top five determinants of compliance and non-compliance. Results: Compliers believed that completing treatment would cure them of TB. Economic prospects were crucial for compliance. Compliers felt that the support of the government disability grant helped with compliance. Non-compliers believed that stigmatization had the greatest impact on non-compliance, together with the burden of disease, the arrangements involved with receiving treatment, restrictions accompanying treatment, and the association of TB with HIV/AIDS infection. Conclusions: Stigmatization makes TB a ‘social disease’. Individual motivation and self-efficacy appear to have a considerable effect on compliance, but, for non-compliers, the general lack of job prospects and being able to provide for themselves or their family also makes TB very much an ‘economic disease’.

Delays in presenting for tuberculosis treatment associated with fear of learning one is HIV-positive

A cornerstone of tuberculosis (TB) control is early diagnosis and treatment. The first hurdle that prospective TB patients must overcome is to present at a public health clinic for treatment. The Global Plan to Stop TB addresses the new challenges of the intersecting epidemics of TB and HIV, and it aims to cut the transmission chain by achieving early and effective treatment of all people with TB infection. This goal may be more difficult to achieve in practice. Findings from a representative community survey conducted in an area of high HIV prevalence in the Eastern Cape Province of South Africa suggest that patients must conquer fear of knowing their HIV status in order to present for TB diagnosis and treatment. A total of 1 020 adults residing in a low-income suburb of Grahamstown, Makana Municipality, participated in a questionnaire survey that probed attitudes and opinions about TB and HIV/AIDS-related issues. The respondents were presented with eight factors previously cited in the literature as causing delays in presenting for TB treatment at a public health clinic. The single largest proportion of respondents attributed delay to a fear of discovering that one is HIV-positive. While the vast majority of the respondents agreed that knowing ones HIV status is a civic responsibility (‘the right thing to do’), half indicated that the lack of privacy during voluntary counselling and testing for HIV at a public health clinic acts as a disincentive. The evidence suggests that a fear of knowing ones HIV status is a deep-seated anxiety that is often not openly acknowledged, and that it is intertwined with the stigma related to the ‘new’ TB associated with HIV and AIDS. It is crucial to allay this deep-seated fear in the general public so that South Africas integrated HIV and TB services, designed to accelerate control of the twin epidemics, are successful.

Comparison of barriers to employment among youth with and without disabilities in South Africa

OBJECTIVE Disability limits access to education and employment, and leads to economic and social exclusion. This study compared barriers to employment among disabled and non-disabled youth in South Africa. METHODS AND PARTICIPANTS Fieldworkers interviewed 989 youth [18-35 years; 523 (52.9%) disabled, 466 (47.1%) non-disabled] at nine sites in five provinces (Gauteng, North West, Kwazulu Natal, Western Cape, Free State). Differences in employment between disabled and non-disabled youth were described and logistic regression analyses were used to predict barriers to employment within both groups. RESULTS Employment differed between disabled and non-disabled youth (32.9% vs. 13.1%; p ⩽ 0.001). Lack of job availability and skills were associated significantly with unemployment among non-disabled youth. For disabled youth, unemployment was additionally associated with social attitudes and poor health. CONCLUSIONS This research showed that disabled youth are facing more barriers to employment compared to non-disabled youth and that the unemployment rate among disabled youth is higher. Disabled youth thus faced additional challenges to employment and special attention must be given to reduce these barriers.

Disabled youth in South Africa: barriers to education

Abstract Background: In South Africa, disability limits access to education and leads to economic and social exclusion. Identifying related barriers is a first step in solving this problem. This study explores barriers to education among disabled youths in South Africa. Methods: Fieldworkers identified households with disabled youths aged 18 to 35 years. A snowball sample consisting of 989 individuals was used in the study. These individuals were interviewed at nine sites in five South African provinces. The sample consisted of 523 (52.9%) disabled and 466 (47.1%) non-disabled youths. Physical disability (n=231, 44.2%) comprised the largest group in the sample, followed by intellectual disability (n=169, 32.3%) the second largest. Differences in education between disabled and non-disabled youth groups were established via χ2-tests. Logistic regression analyses were also used to find educational barriers for disabled youth. Results: As expected, we found a large difference between non-disabled and disabled youths who currently attend or attended school in the past (99.3% vs. 82.4%; p≤0.001). Results from the logistic regression analyses among the disabled youth showed no significant relationship between financial exclusion and education. Social exclusion and exclusion by design were significantly associated with education. Conclusions: The study’s findings suggest that special attention should be given to vulnerable groups who are disproportionally disadvantaged and to the specific education barriers they face, which may require a combination of various interventions. Reducing negative social attitudes requires interventions aimed at teachers and families of disabled youth. Exclusion by design can be reduced through proper information about schools, less difficult admission systems, improved access, and elimination of physical obstacles.

The importance of person‐centred care and co‐creation of care for the well‐being and job satisfaction of professionals working with people with intellectual disabilities

BACKGROUND Person-centred care and co-creation of care (productive interactions between clients and professionals) are expected to lead to better outcomes for clients. Professionals play a prominent role in the care of people with intellectual disabilities at residential care facilities. Thus, person-centred care and co-creation of care may be argued to lead to better outcomes for professionals as well. This study aimed to identify relationships of person-centred care and co-creation of care with the well-being and job satisfaction of professionals working with people with intellectual disabilities (PWID). METHODS A cross-sectional survey was conducted in 2015 among professionals working at a disability care organisation in the Netherlands. All 1146 professionals involved in the care of people with intellectual disabilities who required 24-hours care were invited to participate. The response rate was 41% (n = 466). RESULTS Most respondents (87%) were female, and the mean age was 42.8 ± 11.5 years (22-65). The majority of respondents (70%) worked ≥22 hours per week and had worked for the organisation for ≥5 years (88%). Most of the respondents (76.8%) were direct care workers either in residential homes (59.3%) or in day activities (17.5%). After controlling for background variables, person-centred care and co-creation of care were associated positively with job satisfaction and well-being of professionals. CONCLUSIONS The provision of person-centred care and co-creation of care may lead to better well-being and job satisfaction among professionals working with PWID. This finding is important, as such professionals often experience significant levels of work stress and burnout.

Facilitators and hindrances in the experiences of Ugandans with and without disabilities when seeking access to microcredit schemes.

Purpose: This study aimed to identify facilitators and hindrances in the experiences of Ugandans with and without disabilities when seeking access to microcredit schemes. Method: Thirty-five statements were presented to 80 people, 50 of whom were disabled. Q-methodology was used to identify factors influencing access to microcredit schemes. Results: Running a business independently was solely identified by people with disabilities (PWD) as an important facilitator in accessing microcredit schemes, while relying on business skills was largely mentioned by people without disabilities. The disabled identified family-related items to be inhibiting factors. Having a group loan was ranked negatively by the disabled and ambivalently by the non-disabled. Conclusions: PWD experience different facilitators and barriers to access microcredit schemes compared to the non-disabled. PWD prefer individual loans and believe they can more successfully run a business on their own, instead of relying on family or having a group loan. Furthermore, they would benefit from microcredit schemes that take into account disability-specific circumstances. These are important findings to increase access to microcredit schemes and to let PWD benefit to the same extend from these programmes than do their non-disabled peers. Implications for Rehabilitation Research shows that people with disabilities (PWD) experience limited access to microcredit schemes than their non-disabled peers. Empirical evidence is necessary to increase our understanding of why PWD have less access to microcredit schemes, if this is different from non-disabled and identify the specific hindrances as well as supporting factors. This study showed that PWD experience different facilitators and barriers to access microcredit schemes compared to the non-disabled. PWD prefer individual loans and believe they can more successfully run a business on their own, instead of relying on family or having a group loan. Furthermore, they would benefit from microcredit schemes that take into account disability-specific circumstances.

Prospects for Community-Based Rehabilitation in the New Millennium

Community-based rehabilitation (CBR) is presented as an alternative or complementary approach to rehabilitation in institutions. In developing countries, these institutions are non-existent, or considered inadequate. In the CBR concept, rehabilitation of people with disabilities takes place in the community and relies explicitly on the involvement of lay people, i.e., family members, volunteers, schoolteachers and village community workers. Rehabilitation has gone through a paradigm shift from a medical to a human rights model. Disability is more and more perceived as an impoverishing condition in which the disability and poverty in sync deny people a decent life. Consequently CBR is described as a strategy to improve the socio-economic status of people with disabilities and to improve their quality of life. This article discusses the ‘state of the art’ of CBR and analyses shortcomings of current research in CBR. Evaluations and research rarely focus on outcomes related to community development or the Millennium Development Goals. It is argued that CBR needs interest from researchers from different disciplines and to use their instrumentation or develop it jointly. Quality of Life researchers are challenged to develop these tools with the main stakeholders in CBR.