Surona Visagie

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

Background 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.

Implementation of the principles of primary health care in a rural area of South Africa

Background The philosophy of primary healthcare forms the basis of South Africas health policy and provides guidance for healthcare service delivery in South Africa. Healthcare service provision in South Africa has shown improvement in the past five years. However, it is uncertain as to whether the changes have reached rural areas and if primary healthcare is implemented successfully in these areas. Objectives The aim of this article is to explore the extent to which the principles of primary healthcare are implemented in a remote, rural setting in South Africa. Method A descriptive, qualitative design was implemented. Data were collected through interviews and case studies with 36 purposively-sampled participants, then analysed through Interpretative Phenomenological Analysis. Results Findings indicated challenges with regard to client-centred care, provision of health promotion and rehabilitation, the way care was organised, the role of the doctor, health-worker attitudes, referral services and the management of complex conditions. Conclusion The principles of primary healthcare were not implemented successfully. The community was not involved in healthcare management, nor were users involved in their personal health management. The initiation of a community-health forum is recommended. Service providers, users and the community should identify and address the determinants of ill health in the community. Other recommendations include the training of service managers in the logistical management of ensuring a constant supply of drugs, using a Kombi-type vehicle to provide user transport for routine visits to secondary- and tertiary healthcare services and increasing the doctors’ hours.

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

Background 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 District Health 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.

A description of assistive technology sources, services and outcomes of use in a number of African settings.

Abstract Purpose statement: The article explores assistive technology sources, services and outcomes in South Africa, Namibia, Malawi and Sudan. Methods: A survey was done in purposively selected sites of the study countries. Cluster sampling followed by random sampling served to identify 400–500 households (HHs) with members with disabilities per country. A HH questionnaire and individual questionnaire was completed. Country level analysis was limited to descriptive statistics. Results: Walking mobility aids was most commonly bought/provided (46.3%), followed by visual aids (42.6%). The most common sources for assistive technology were government health services (37.8%), “other” (29.8%), and private health services (22.9%). Out of the participants, 59.3% received full information in how to use the device. Maintenance was mostly done by users and their families (37.3%). Devices helped a lot in 73.3% of cases and improved quality of life for 67.9% of participants, while 39.1% experienced functional difficulties despite the devices. Conclusion: Although there is variation between the study settings, the main impression is that of fragmented or absent systems of provision of assistive technology. Implications for rehabilitation Provision of assistive technology and services varied between countries, but the overall impression was of poor provision and fragmented services. The limited provision of assistive technology for personal care and handling products is of concern as many of these devices requires little training and ongoing support while they can make big functional differences. Rural respondents experienced more difficulties when using the device and received less information on use and maintenance of the device than their urban counterparts. A lack of government responsibility for assistive device services correlated with a lack of information and/or training of participants and maintenance of devices.

Environmental factors influencing participation of stroke survivors in a Western Cape setting

Background Environmental factors compound or diminish the effects of impairments; therefore they have a direct influence on participation of stroke survivors. Objectives To determine environmental barriers and facilitators to participation experienced by a group of stroke survivors in the Western Cape province of South Africa. Methods A descriptive, mixed methods study was conducted in 2011. Quantitative data was collected with the International Classification for Functioning, Disability and Health core set for stroke (environmental factors), from 53 stroke survivors, sampled through proportional, stratified, random sampling. Data is presented through graphs and tables. Qualitative data was collected from five purposively sampled participants and thematically analysed. Results Under products and technology, participants regarded assets, food, products and technology for daily living, transportation, mobility and communication, and access to buildings as barriers. The physical geography and attitudes of friends and society created further barriers. With regard to services, systems and policies - housing, communication, transport and social services created barriers. Health services, as well as support from health care service providers and family were considered facilitators. Conclusion A lack of assets compounded barriers with regard to food, products for daily use, communication and transport. Barriers to participation were exacerbated by a lack of services, systems and implementation of policies focused on the inclusion of people with disabilities, as well as minimal access to assistive devices. Recommendations include provision of assistive devices, structural changes to houses, yards, roads and buildings, lobbying for accessible, affordable public transport, access audits of public buildings, and inclusion of non-governmental organisations and home-based care services in a seamless network of care.

Factors related to environmental barriers experienced by persons with and without disabilities in diverse African settings

This paper explores differences in experienced environmental barriers between individuals with and without disabilities and the impact of additional factors on experienced environmental barriers. Data was collected in 2011–2012 by means of a two-stage cluster sampling and comprised 400–500 households in different sites in South Africa, Sudan Malawi and Namibia. Data were collected through self-report survey questionnaires. In addition to descriptive statistics and simple statistical tests a structural equation model was developed and tested. The combined file comprised 9,307 participants. The Craig Hospital Inventory of Environmental Factors was used to assess the level of environmental barriers. Transportation, the natural environment and access to health care services created the biggest barriers. An exploratory factor analysis yielded support for a one component solution for environmental barriers. A scale was constructed by adding the items together and dividing by number of items, yielding a range from one to five with five representing the highest level of environmental barriers and one the lowest. An overall mean value of 1.51 was found. Persons with disabilities scored 1.66 and persons without disabilities 1.36 (F = 466.89, p < .001). Bivariate regression analyses revealed environmental barriers to be higher among rural respondents, increasing with age and severity of disability, and lower for those with a higher level of education and with better physical and mental health. Gender had an impact only among persons without disabilities, where women report more barriers than men. Structural equation model analysis showed that socioeconomic status was significantly and negatively associated with environmental barriers. Activity limitation is significantly associated with environmental barriers when controlling for a number of other individual characteristics. Reducing barriers for the general population would go some way to reduce the impact of these for persons with activity limitations, but additional and specific adaptations will be required to ensure an inclusive society.

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

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.

Rural South Africans’ rehabilitation experiences: Case studies from the Northern Cape Province

Background Rehabilitation is often challenging in South Africa, but South Africans living in remote rural settings might experience unique challenges. Objective This article interrogates issues of access to rehabilitation in a selected sample from rural South Africa through case studies. Method This qualitative study utilised a case study design. Eight case studies were done in a purposively sampled rural town in the Northern Cape Province. Data were collected through in-depth interviews. Data were analysed according to the principles of interpretative phenomenological analysis. Results The case study participants were not integrated into the community. They experienced higher levels of disability than one would expect from their impairments. Their impairments were not modified. No retraining of function was implemented. Early intervention and childhood development activities were not provided. Participants were not linked with self-help or peer support groups. Provision of assistive devices was challenged. Environmental barriers aggravated the situation. Conclusion We theorise that one-on-one therapy is not the solution to the rehabilitation needs of persons with disabilities in remote, rural settings. We recommend a move to community-based rehabilitation and transdisciplinary teamwork supported by family members, community health workers and peer mentors. Therapists are ideally situated to explore the feasibility of such programmes and to pilot them in various communities.

Is any wheelchair better than no wheelchair? A Zimbabwean perspective

Background 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.

Exploring the impact of wheelchair design on user function in a rural South African setting

Background Wheelchairs provide mobility that can enhance function and community integration. Function in a wheelchair is influenced by wheelchair design. Objectives To explore the impact of wheelchair design on user function and the variables that guided wheelchair prescription in the study setting. Method A mixed-method, descriptive design using convenience sampling was implemented. Quantitative data were collected from 30 wheelchair users using the functioning every day with a Wheelchair Scale and a Wheelchair Specification Checklist. Qualitative data were collected from ten therapists who prescribed wheelchairs to these users, through interviews. The Kruskal-Wallis test was used to identify relationships, and content analysis was undertaken to identify emerging themes in qualitative data. Results Wheelchairs with urban designs were issued to 25 (83%) participants. Wheelchair size, fit, support and functional features created challenges concerning transport, operating the wheelchair, performing personal tasks, and indoor and outdoor mobility. Users using wheelchairs designed for use in semi-rural environments achieved significantly better scores regarding the appropriateness of the prescribed wheelchair than those using wheelchairs designed for urban use (p = <0.01). Therapists prescribed the basic, four-wheel folding frame design most often because of a lack of funding, lack of assessment, lack of skills and user choice. Conclusion Issuing urban type wheelchairs to users living in rural settings might have a negative effect on users’ functional outcomes. Comprehensive assessments, further training and research, on long term cost and quality of life implications, regarding provision of a suitable wheelchair versus a cheaper less suitable option is recommended.