Towards a needs-based design of the physical rehabilitation workforce in South Africa: trend analysis [1990-2017] and a 5-year forecasting for the most impactful health conditions based on global burden of disease estimates

Context factors for implementation of clinical recommendations for chronic musculoskeletal pain

BACKGROUND

 Implementing evidence-informed clinical practice recommendations is important for managing chronic musculoskeletal pain (CMSP) to address the multidimensional impact of the condition. Successful implementation of recommendations requires understanding the multiple context factors that influence CMSP management in different settings.

AIM

 This study aims to explore contextual factors that could influence the implementation of evidence-informed clinical practice recommendations for the primary health care of adults with CMSP.

SETTING

 The study focused on the primary health care (PHC) sector in Cape Town, South Africa.

METHODS

 A qualitative descriptive study was conducted. A multidisciplinary panel of 13 local health care professionals participated in focused group discussions. The participants considered multimodal clinical recommendations derived from published clinical practice guidelines. In four focus group discussions (three or four members per group), the panel generated and documented context factors that would influence implementing the recommendations in practice. Inductive content analysis was performed to identify categories and themes.

RESULTS

 The five contextual themes generated indicated health care system organisation, human resource requirements, provider practice patterns, patient empowerment and integration into policy as imperative for the successful implementation of recommendations.

CONCLUSION

 There are diverse context factors that could influence the implementation of clinical recommendations for managing CMSP in PHC settings. Identifying these factors as barriers or facilitators is beneficial for developing effective knowledge translation strategies.Contribution: The study findings indicate that an integrated systems approach supported by health care policy and multisectoral collaboration is needed to successfully implement clinical recommendations to address the impact of CMSP.

Understanding the value of rehabilitation: Perspectives from South African Stakeholders

Background

The need for rehabilitation in South Africa has doubled between 1990 and 2017 and is expected to increase in the coming years. However, the rehabilitation needs of South Africans (and globally) remain largely unmet. Establishing a common understanding of the value of rehabilitation can inform clinical practice and policymaking to achieve Universal Health Coverage (UHC).

Objectives

This study aims to explore the value of rehabilitation services in South Africa's public healthcare sector by gathering perspectives from stakeholders. The goal is to inform policy decisions related to the implementation of National Health Insurance (NHI) in South Africa.

Method

The study used a phenomenological approach and interpretivist paradigm. Semi-structured interviews were conducted face-to-face, online, or telephonically with 12 stakeholders from various rehabilitation sectors. The value of rehabilitation was analysed and categorised into five main categories: context, service delivery, patient outcomes, economic and financial components, and collaboration within and between sectors.

Results

The value of rehabilitation was found to be multifaceted, because of the varying health, economic, and social challenges faced by many South Africans.

Conclusion

The study identified components of value-based rehabilitation that should be prioritised in the proposed NHI of South Africa. Future research should explore all stakeholder perspectives, including patients, and provide empirical evidence of rehabilitation's economic and societal value.

Contribution

We highlight priority areas that are central to the value of rehabilitation in South Africa and other low- and middle-income countries (LMICs). Tailoring rehabilitation services to patient and community needs is crucial for achieving value-based care. Given South Africa's commitment to the United Nations Convention on the Rights of Persons with Disabilities, prioritising rehabilitation remains essential.

Let the records speak: an exploration of rehabilitation services offered in primary healthcare, Johannesburg metropolitan district

BACKGROUND

Primary healthcare in South Africa aims to transform the national health system by emphasising community-based care and preventive strategies. However, rehabilitation services, particularly for individuals with disabilities and chronic non-communicable diseases, are often overlooked in primary healthcare. This study aimed to investigate the provision of primary healthcare rehabilitation services in the Johannesburg Metropolitan District by exploring client sociodemographics and variations in services provided by rehabilitation professionals.

METHODS

A retrospective review of clinic rehabilitation records from 2011 to 2020 was conducted at nine provincially funded community health centres (CHCs) offering rehabilitation services. Stratified sampling facilitated record selection based on rehabilitation service type and year. A specifically designed data extraction tool captured demographics, disabilities, rehabilitation received, and referral sources. Descriptive analysis used means, standard deviations, and frequencies.

RESULTS

The findings show a diverse client population with a wide age range, with a significant proportion falling into the < 5 years and 30-49 years age groups. Neuromusculoskeletal and movement-related disabilities were most prevalent, affecting approximately two-thirds of clients. Referral sources were often undocumented, and inconsistent discharge information with no record of patient follow up, highlighted the need for improved documentation practices. Clinic visits were the primary service delivery mode, followed by limited home visits and outreach services. Occupational therapy and physiotherapy were the most used services. Speech and language therapy services were underused, and some CHCs lacked audiology services. There were variations in the number of individual and group sessions provided by the different rehabilitation services, and there were age- and disability-specific differences in service use.

CONCLUSION

This study offers insights into rehabilitation service provision in the Johannesburg Metropolitan District and enhances our understanding of rehabilitation services in primary healthcare settings. It underscores the importance of a multidisciplinary rehabilitation team to address diverse rehabilitation needs, improving documentation and discharge practices, expanding service delivery models, and reducing disparities in service use. The findings inform strategies for optimising service delivery, workforce, resource allocation, and intersectoral collaboration to ultimately enhance the quality and accessibility of integrated rehabilitation services.

Availability of resources for paediatric hearing care in a South African province

BACKGROUND

 Unavailability of healthcare resources can lead to poor patient outcomes. The latter is true for infants with hearing loss and require early hearing detection and intervention (EHDI).

AIM

 To determine the availability and distribution of resources for EHDI in state hospitals in the Eastern Cape (EC) province, South Africa.

SETTING

 Sixteen state hospitals (nine district, four regional and three tertiary hospitals).

METHODS

 Descriptive cross-sectional survey completed between July 2022 and October 2022.

RESULTS

 Thirteen hospitals had audiologists (n = 4) or speech therapists and audiologists (n = 9). Specific to equipment, 10 hospitals had a screening otoacoustic emissions or automated auditory brainstem response, 8 hospitals had diagnostic middle ear analysers and only 3 hospitals had diagnostic auditory brainstem response and/or auditory steady state response. Twelve hospitals did not have visual response audiometry (VRA) and 94% had no hearing aid verification systems. Budget allocations were uneven, with only 10 hospitals, i.e., 4 districts, all regional and 2 tertiary hospitals being allocated varying amounts. Subsequently, only 50% provided newborn hearing screening, 56% provided diagnostic evaluations and 14 hospitals fitted hearing aids.

CONCLUSION

 Results revealed a limited and uneven distribution of resources, which negatively impacted the provision of EHDI. Even distribution of healthcare resources and further research aimed at strengthening hearing health services is recommended as these could potentially improve equitable access to EHDI and the overall quality of healthcare provided.Contribution: This study highlights the need for even distribution of resources and strengthening of health systems, especially in the dawn of the National Health Insurance.

Rehabilitation Capacity in South Africa-A Situational Analysis

Rehabilitation in South Africa (SA) operates independently of major health services and reforms, despite the increasing rehabilitation need. With the introduction of National Health Insurance (NHI), SA is facing another major health reform. Evidence is needed on the current SA rehabilitation situation, regarding shortcomings, opportunities, and priority strategic strengthening actions. We aimed to describe the current rehabilitation capacity in the SA public health sector, which serves the majority and most vulnerable South Africans. A cross-sectional survey was conducted in five provinces, using the World Health Organisation's Template for Rehabilitation Information Collection (TRIC). Participants were purposively selected for their insights and experiences of rehabilitation in specific government departments, health sectors, organisations, and/or services. TRIC responses were analysed descriptively. Participants explained how timely and effective rehabilitation produced long-term health, social, and economic benefits. Positive initiatives were reported for rehabilitation data collection, service design, and innovation. Challenges included inadequacies in human resources, the integration of rehabilitation at primary care, guidelines, and specialised long-term care facilities. The continuity of care across levels of care was sub-optimal due to inefficient referral systems. Promoting and improving rehabilitation nationally requires concerted, innovative, collaborative, and integrated efforts from multiple stakeholders within, and outside, the health system.

Expanding access to rehabilitation using mobile health to address musculoskeletal pain and disability

Introduction

Musculoskeletal (MSK) disorders such as low back pain and osteoarthritis are a leading cause of disability and the leading contributor to the need for rehabilitation services globally. This need has surpassed the availability of trained clinicians; even in urban areas where services and providers are thought to be more abundant, access can be challenged by transportation options and financial costs associated with travel, care and lost time from work. However, continuing standard of fully in-person rehabilitation care for MSK-associated pain and disability may no longer be necessary. With increased ownership or access to even a basic mobile phone device, and evidence for remote management by trained clinicians, some individuals with MSK disorders may be able to continue their rehabilitation regimen predominantly from home after initial evaluation in primary care or an outpatient clinic.

Methods

This manuscript describes application of a framework we used to culturally and contextually adapt an evidence-based approach for leveraging digital health technology using a mobile phone (mHealth) to expand access to rehabilitation services for MSK-associated pain and disability. We then conducted a multi-level analysis of policies related to the adapted approach for rehabilitation service delivery to identify opportunities to support sustainability.

Results

Our study was conducted in Tanzania, a lower-middle income country with their first National Rehabilitation Strategic Plan released in 2021. Lessons learned can be applied even to countries with greater infrastructure or fewer barriers. The seven-step adaptation framework used can be applied in other regions to improve the likelihood of local mHealth adoption and implementation. Our practice and policy assessment for Tanzania can be applied in other regions and used collaboratively with government officials in support of building or implementing a national rehabilitation strategic plan.

Conclusion

The work described, lessons learned and components of the plan are generalizable globally and can improve access to rehabilitation services using mHealth to address the significant and increasing burden of disability.

Functioning Problems Associated with Health Conditions with Greatest Disease Burden in South Africa: A Scoping Review

A notable rise in health-related disability for which evidence-based rehabilitation is beneficial is evident in low-to-middle income countries. This scoping review aimed to systematically identify and map the most common functioning problems associated with health conditions that contribute most to disability in South Africa using the International Classification of Functioning, Disability and Health (ICF) framework. Peer-reviewed evidence published from January 2006 to December 2021 was systematically searched from five databases. Some 268 studies reporting on functioning problems (impairments, activity limitations, and participation restrictions) in South African adults (>18 years) related to 10 health conditions were included. A total of 130 different functioning problems were mapped to the ICF. The most prevalent problems (top 20) were related to mobility, pain, and mental health but spanned across several ICF domains and were mostly in patients at primary care. The high prevalence and wide range of functioning problems may be particularly burdensome on an already strained primary health care (PHC) system. This points towards targeted planning of innovative strategies towards strengthening rehabilitation service delivery at primary care to address these complexities where there is an inadequate rehabilitation workforce.

Rehabilitation and primary care treatment guidelines, South Africa

The World Health Organization recognizes rehabilitation as an essential component of universal health coverage (UHC). In many countries, UHC builds on a standard benefits package of services that is informed by the country’s essential medicines list, standard treatment guidelines and primary health care essential laboratory list. In South Africa, primary health care is largely provided and managed by primary health-care nurses and medical officers in accordance with primary health care standard treatment guidelines. However, rehabilitation is mostly excluded from these guidelines. This paper describes the 10-year process that led to rehabilitation referral recommendations being considered for inclusion in South Africa’s primary health care standard treatment guidelines. There were five key events: (i) a breakthrough moment; (ii) producing a scientific evidence synthesis and formulating recommendations; (iii) presenting recommendations to the national essential medicines list committee; (iv) mapping rehabilitation recommendations onto relevant treatment guideline sections; and (v) submitting revised recommendations to the committee for final consideration. The main lesson learnt is that, by working together, rehabilitation professionals can be of sufficient number to make a difference, improve service delivery and increase referrals to rehabilitation from primary health care. A remaining challenge is the lack of a rehabilitation representative on the national essential medicines list committee, which could hamper understanding of rehabilitation and of the complexities of the supporting evidence.

Describing the Rehabilitation Workforce Capacity in the Public Sector of Three Rural Provinces in South Africa: A Cross-Sectional Study

The World Health Organisation emphasises the importance of addressing gaps in health systems where rehabilitation services are poorly integrated. In South Africa, regions with the largest disability rates are usually the areas where rehabilitation is least accessible, due to inadequate workforce capacity. The first step towards addressing workforce capacity is to determine current capacity. This paper presents a cross-sectional study to describe rehabilitation workforce data in the public sector of three rural South African provinces. A web-based therapist survey and a telephonic facility survey was conducted. Data were collected regarding total number of therapists per province, age, years employed, qualifications, salary level, profession type, level of care, and rural/urban distribution. Descriptive statistics were conducted, while Chi-squared tests compared professions regarding highest qualification and salary level. Population-adjusted ratios were calculated using national uninsured population statistics. The web-based survey had 639 responses while the telephonic survey reported on 1166 therapists. Results indicated that the mean age of therapists across the respective provinces was 28, 35 and 31 years of age, and the mean employment years in the respective provinces were three, eight and five years. Most of the workforce (n = 574) had a bachelor's degree as their highest qualification. A total of 27% of the workforce were community service therapists and 61% of therapists earned a production-level salary. Occupational therapy was best (40%) and speech and audiology therapy least (7%) represented. Three percent of therapists worked at primary level, versus eighty percent at secondary level. Forty percent of therapists worked in rural areas. Workforce density per province ranged from 0.71-0.98 per 10,000 population. Overall, results show that the rehabilitation workforce density is low, and that the distribution of therapists between rural and urban settings, and levels of care, is inequitable. Considering the rise in rehabilitation need, prioritisation and strengthening of the rehabilitation workforce capacity is vital to ensure integration across all levels of care and service.

Development of an innovative strategy to determine functioning attributed to health conditions in low-resource settings

Objectives

Rehabilitation is a health strategy that aims to reduce functioning problems. There is a lack of country-level data on the burden and type of functioning problems to inform service planning and management of patients' rehabilitation needs, particularly at primary care level in low-resource settings. Health researchers need an application that automates synthesis of data extracted from several peer-reviewed publications to determine the most prevalent functioning problems compared across several health states. This article describes the journey leading to the conceptualization and development of the Rehab4all application and compares the application's performance to a standard desktop program.

Methods

A descriptive case study approach was used to report on the following steps involved in the development of the web-based Rehab4all application: (i) preliminary literature review to assess the evidence gap of country-level data on functioning problems comparable across several health states; (ii) an initial attempt to perform data extraction and synthesis in Excel; (iii) design and development of Rehab4all; (iv) piloting of the Rehab4all application; and (v) implementation of application with input data from South Africa and Zimbabwe.

Results

The Rehab4all application offers a feasible solution for synthesizing data from several peer-reviewed publications to provide information on context-specific, priority functioning problems at country level through the integrated global International Classification of Functioning, Disability and Health Framework (ICF).

Conclusion

This bespoke innovation provides impetus for further development, profile comparison and shared information between countries to co-develop strategies which can strengthen rehabilitation service delivery.